Document of The World Bank Report No: 24992-RW PROJECT APPRAISAL.DOCUMENT ONA PROPOSED GRANT IN THE AMOUNT OF SDR 22.2 MILLION (US$30.5 MILLION EQUIVALENT) TO THE REPUBLIC OF RWANDA FOR A MULTI-SECTORAL HIV/AIDS PROJECT IN SUPPORT OF THE SECOND PHASE OF THE US$ 500 MILLION MULTI-COUNTRY HIV/AIDS PROGRAM (MAP2) FOR THE AFRICA REGION March 11, 2003 Human Development Unit m Country Department 9 Africa Regional Offlce CURRENCY EQUIVALENTS (Exchange Rate Effective ) Currency Unit = RwF (Rwanda Franc) 51ORwF = US$1.00 US$1.37 =1.00 SDR FISCAL YEAR January 1 - December31 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency Syndrome APL Adaptable Program Loan ANSP National Association of People Living with AIDS APR Rwandan Patriotic Army ARV Anti-retroviral (Drugs) ART Anti-Retroviral Treatment BCC Behavior Change Communications CAMERWA Rwandan Central Drug Procurement and Distribution Agency CAS Country Assistance Strategy CDLS District HIV/AIDS Commission CNJ National Youth Council CNLS National HIV/AIDS Commission CPLS Provincial HIV/AIDS Commission CRIS Centre Rwandais dInformation sur le SIDA DHS Demographic and Health Survey EU European Union FOJAS National Youth Forum against AIDS GLIA Initiative against AIDS in the Great Lakes Countries GOR Government of Rwanda HIPC Highly Indebted Poor Countries HIV Human Immuno-Deficiency Virus IEC Information Education and Communication MAP 11 Multi-country HIV/AIDS Program II for the Africa Region MINISANTE Ministry of Health NGO Non-Goveirnental Organization PIP Project Implementation Plan PLWHA People Living with HIV/AIDS PMU Project Management Unit PNLS National AIDS Program PRSP Poverty Reduction Strategy Paper PMTCT Prevention Mother to Child Transmission RH Reproductive Health SDR Special Drawing Rights STIs Sexually Transmitted Infections SWAA African Society of Women for the fight against AIDS TB Tuberculosis TRAC Research and Treatment Center on AIDS UNAIDS United Nations organization for the fight against AIDS UNICEF United Nations Children's Fund UNHCR United Nations High Commission for Refugees VCT Voluntary Counseling and Testing WHO World Health Organization Vice President: Callisto E. Madavo Country Director: Emmanuel Mbi Sector Manager: Laura Frigenti Task Team Leader: Miriam Schneidman REPUBLIC OF RWANDA MULTI-SECTORAL HMVAIDS PROJECT CONTENTS A. Program Purpose and Project Development Objective Page 1. Program purpose and program phasing 2 2. Project development objective 2 3. Key performance indicators 2 B. Strategic Context 1. Sector-related Country Assistance Strategy (CAS) goal supported by the project 4 2. Main sector issues and Government strategy 4 3. Sector issues to be addressed by the project and strategic choices 11 4. Program description and performance triggers for subsequent loans 12 C. Program and Project Description Summary 1. Project components 12 2. Key policy and institutional reforms supported by the project 16 3. Benefits and target population 17 4. Institutional and implementation arrangements 18 D. Project Rationale 1. Project alternatives considered and reasons for rejection 23 2. Major related projects financed by the Bank and/or other development agencies 24 3. Lessons Learned and reflected in the project design 25 4. Indications of recipient commitment and ownership 27 5. Value added of Bank support in this project: 27 E. Summary Project Analysis 1. Economnic 27 2. Financial 28 3. Technical 28 4. Institutional 31 5. Environrmental 33 6. Social 34 7. Safeguard Policies 35 F. Sustainability and Risks 1. Sustainability 36 2. Critical risks 37 3. Possible controversial aspects 38 G. Main Conditions 1. Effectiveness Condition 38 2. Other 38 H. Readiness for Implementation 38 I. Compliance with Bank Policies 39 Annexes Annex 1: Project Design Summary 40 Annex 2: Detailed Project Description 48 Annex 3: Estimated Project Costs 58 Annex 4: Cost Benefit Analysis Summary, or Cost-Effectiveness Analysis Summary 59 Annex 5: Financial Summary for Revenue-Eaning Project Entities, or Financial Summary 60 Annex 6: (A) Procurement Arrangements 61 (B) Financial Management and Disbursement Arrangements 71 Annex 7: Project Processing Schedule 79 Annex 8: Documents in the Project File 81 Annex 9: Statement of Loans and Credits 84 Annex 10: Country at a Glance 85 Annex 11: Monitoring and Evaluation 87 Annex 12: Epidemiological Situation 93 Annex 13: Project Supervision 100 Annex 14: Orphans and Vulnerable Children 102 Annex 15: HIV/AIDS Donor Activities 108 MAP(S) IBRD 32003 REPUBLIC OF RWANDA Multi-Sectoral HlV/AIDS Project Project Appraisal Document Africa Regional Office AFTH3 Date: March 11, 2003 Team Leader: Miriam Schneidman Sector Manager: Laura Frigenti Sector(s): Other social services (100%) Country Director: Emmanuel Mbi Theme(s): Fighting communicable diseases (P), Social Project ID: P071374 risk coping (S) Lending Instrument: Adaptable Program Loan (APL) -, - 1- -7"-' 'PrSogr mdE inaicaive Fata:-bn t --- _--^X '..-' ,tK r-m,e~~ ion~ y.-- z . _ _ _ __ _ _ _ n; *. d! ......... ... % d IBRD Others Total Commitment Closing US$ m % US$ m US$ m Date Date APL L1r oan 30.50 95.3 ; 1.50 32.00 T 10/30/2008 Government of Rwanda n W.0~~~~~~~~ Loanl . I~~~~~~~~~~-Bn Y)-1 Credit________ _________ ________j_____ __ Total 30.50 1.50 32.00 [ ] Loan [ ] Credit [X] Grant [ l Guarantee [ l Other: For Loans/CreditstOthers: Amount (US$m): $32 Financin P0Ian (US$m): ; Spurcte -. ' . . - _--t= Local t Foreign.: -. . -Totall-~-~ BORROWER/RECIPIENT 1.49 0.01 1.50 IDA GRANT FOR HIV/AIDS 21.12 9.38 30.50 Total: 22.61 9.39 32.00 Borrower/Recipient: GOVERNMENT OF RWANDA Responsible agency: HIV/AIDS NATIONAL COMMISSION (CNLS) Commission Nationale de Lutte contre le SIDA Address: Boulevard Umuganda Commune Kacyiru Kigali Rwanda Contact Person: Dr. Agnes Binagwaho Tel: 250-582018 Fax: 250-5833543 Email: cnls@rwandal.com Estimated Disbursements ( Bank FY/US$m): .} .;Z-.,iFY 2; 7003 - | -'000 ^- l - :-..0 l.'0.06 . .|_r;2 | 2008 | 2 ! | X Annual 0.30 5.10 5.60 6.20 6.30 5.80 1.20 Cumulative 0.30 5.40 11.00 17.20 23.50 29.30 30.50 Project implementation period: 5 years Expected effectiveness date: 07/15/2003 Expected closing date: 10/30/2008 A. Program Purpose and Project Development Objective 1. Program purpose and program phasing: N/A 2. Project development objective: (see Annex 1) The proposed project is part of the Multi-country HIV/AIDS Program for the Africa Region (MAP II) approved on December 20, 2001. In accordance with the main goal of the MAP, the objectives of this operation are: (i) to strengthen prevention measures in order to slow down the spread of HIV/AIDS, and (ii) to expand support and care for those infected or affected by HIVIAIDS. These objectives will be attained through the use of a multi-sectoral approach, supporting activities undertaken by public and private organizations and by civil society. The project will support the implementation of Rwanda's 2002-2006 Strategic HIV/AIDS Plan which has been prepared in a participatory fashion and has broad based support within the country. 3. Key performance indicators: (see Annex 1) International experience has demonstrated that it will be difficult to achieve a measurable impact in terms of reductions in HIV/AIDS prevalence rates within the life of this project. Hence, the major focus of this 5-year project will be on monitoring a core set of outcome, output and process indicators, as shown below and as described in detail in the logical framework. Annex 11 includes a set of interim indicators for assessing overall implementation performance 18 months after grant effectiveness. Outcome indicators The main outcome indicators to be used in assessing effectiveness of preventive measures relate to changes in sexual behavior, as measured by: o Condom utilization rates at last higher risk sex among sexually active men based on data from Demographic and Health Survey (DHS): - By 2008, 70 percent of men (15-49 years) report condom use the last time they had sex with an unmarried, non-cohabitating partner in the last twelve months (2000 baseline of 51 percent). o Condom utilization rates among young people engaging in premarital sex as measured by the Behavioral Surveillance Survey (BSS): - By 2008, 40 percent of never-married young men (15-24 years) report condom use at last sex with a non-commercial partner (2000 baseline of 19.6 percent). - By 2008, 25 percent of young (15-24 years) never-married women report condom use at last sex with a non-commercial partner (2000 baseline of 11.3 percent). o Age at first sex among young people as measured by the BSS: - By 2008, the reported age of first sex among young men (15-19 years) is 14 years (2000 baseline of 13 years at first sex). - By 2008, the reported age of first sex among young women (15-19 years) is 15 years (2000 baseline of 14 years at first sex). The main outcome indicators to be used in measuring care & support efforts are changes in quality of health service delivery and services provided to orphans and vulnerable children, as follows: o Proportion of clients who are appropriately diagnosed and treated for sexually transmitted infections - 2 - (STIs) according to National Guidelines: - By 2008, 80 percent of STI clients are appropriately diagnosed and treated according to the Syndromic Management approach (2002 baseline from MOH/TRAC of 66.5 percent). * Proportion of reported tuberculosis cases who are appropriately diagnosed and treated according to National Guidelines: - By 2008, 85 percent of smear-positive TB cases complete the DOTS protocol (2002 baseline from PNILT of 75 percent). * Ratio of orphaned children aged 10-14 who have lost both parents who are currently attending school to non-orphaned children the same age who are attending school as measured by the DHS: - By 2008, there will be a reduction of 20 percent in differential school attendance ratio between male orphans aged 10-14 (who have lost both parents) and non-orphans (2000 baseline from DHS of 0.76). - By 2008, there will be a reduction of 20 percent in differential school attendance ratio between female orphans aged 10-14 (who have lost both parents) and non-orphans (2000 baseline from DHS of 0.86). Output indicators The-output indicators would focus on improvements in: * Knowledge levels with regard to HIV/AlDS among men and women of reproductive age as measured by Demographic and Health Surveys: - By 2008, 80 percent of men (15-49 years) report accurate knowledge that people can protect themselves from contracting HIV by using condoms and having sex only with one faithful, uninfected partner (2000 baseline composite measure from DHS of 69 percent). - By 2008, 70 percent of women (15-49 years) report accurate knowledge that people can protect themselves from contracting H1V by using condoms and having sex only with one faithful, uninfected partner (2000 baseline composite measure from DHS of 54 percent). * Proportion of women attending antenatal clinics who utilize VCT services as reported by the Ministry of Health (TRAC/PMTCT Section). * By 2008, 95 percent of pregnant women accept counseling and testing services offered at antenatal clinics (2002 baseline from MOH/TRAC of 80.7 percent). * Proportion of HIrV tests conducted at health centers that are performed and read accurately as validated by the National Laboratory's standard quality control assessments. * By 2008, 99 percent of quality control samples provide the same results at the National Laboratory as at health centers, with respect to HIV tests conducted as part of VCT programs (2002 baseline of 90 perent from MOH/TRAC/Referral Laboratory). Process indicators * By 2008, 80 percent of line ministries have prepared HIV/AIDS work plans. * By 2008, 70 percent of Provincial HIV/AIDS Committees (CPLS) are functional, as defined by being fully staffed and having an approved work program. * By 2008, the number of sub-grants awarded under the civil society component of the project are -3 - increasing by 25 percent each year. B. Strategic Context 1. Sector-related Country Assistance Strategy (CAS) goal supported by the project: (see Annex -1) Document number: 24501-RW Country Assistance Strategy Date of latest CAS discussion: November 21, 2002 The 1998 Country Assistance Strategy (CAS) was prepared following the tragic events of the mid 1990s. The CAS focused on five themes: (i) continuation of efforts to reintegrate refugees and to promote national reconciliation; (ii) revitalization of the rural economy through increases in agricultural productivity, protection of natural resources, provision of social and economic infrastructure and improvement of rural markets; (iii) investment in human resources development and capacity building to develop a skilled labor force and improve the welfare of the population; (iv) support for policy and regulatory reforms and selected infrastructure investments to promote private sector trade and investment, and improve Rwanda's competitiveness; and (v) improved donor coordination and resource mobilization. The Executive Directors of the World Bank discussed the CAS Progress Report in June 1999. In December 2000, the Boards of the RMF and the World Bank approved decision point proposals for debt relief for Rwanda under the Enhanced Heavily Indebted Poor Countries (HIPC) initiative. HIV/AlDS is a key area being monitored in the context of the HilPC initiative. Rwanda completed its first Poverty Reduction Strategy Paper (PRSP) following extensive consultations in June 2002. The latest CAS (November 21, 2002) report reviews recent developments and challenges facing Rwanda and outlines the following themes for Bank support: (i) revitalization of the rural economy, (ii) private sector development and employment creation, (iii) human and social development, and (iv) improvement in governance and the effectiveness of public sector actions. The proposed project is part of the FY03 lending program. It is in this context that the current project is proposed for Bank assistance under the MAP framework. As described in the November 2002 CAS, the use of grant funding for this MAP operation is in line with the IDA 13 grant allocation to Rwanda as a debt-vulnerable IDA-only low-income country and complies with the grant implementation guidelines of August 12, 2002. 2. Main sector issues and Government strategy: Country Context Rwanda continues to face huge development challenges, some which are long standing and others which stem from the post-conflict environment. The war and genocide resulted in massive loss of health and other professionals, destruction of the health infrastructure and general impoverishment of the population. During the pre-genocide period escalating fighting and mounting insecurity led to a drop in agricultural production, which exacerbated malnutrition levels and contributed to increases in infant and under five mortality. Following the 1994 genocide, there was a massive economic downturn, which resulted in devastating social and economic effects. Per capita income dropped from about US$370 in 1990 to roughly US$250 in 1999 with about 60 percent of households now estimated to fall below the poverty line. This extreme poverty, combined with loss of human resources, poses enormous challenges. The post-genocide government is making a concerted effort to rebuild civil society, reintegrate large numbers of recently returned refugees and demobilized soldiers, ensure food security and provide basic public services. The HIV/AIDS epidemic poses another major challenge. -4 - Epidemiological Situation Rwanda is currently among the ten most heavily affected African countries by the HIV/AIDS epidemic. With an overall HIV prevalence rate of 11 to 13 percent, AIDS has emerged as the most important public health issue. Data from the late 1990s indicate that up to 30 percent of pregnant women in antenatal clinics in Kigali and 15 percent in rural areas tested positive. HIV prevalence rates among male STI clinic attendees were as high as 55 percent in various surveys. The major causes of the epidemic are the high rates of multiple sex partners, early onset of sexual activity (i.e. 13 for boys; 14 for girls), and the overall crisis of the 1990s. The links between H[V/AIDS epidemic and gender issues are well known, as noted in the figure below. In Rwanda these issues were exacerbated by the genocide which resulted in massive rape of women and a rise in poverty and vulnerability. It is estimated that a staggering one-third of households in Rwanda are headed by females who are economically, socially and sexually vulnerable. Young people (i.e. under 20 years of age), who comprise 60 percent of the population, are particularly vulnerable with prevalence rates estimated at 10 percent in 1997. The youngest age group (12-14 years) was found to have a prevalence rate of about 4 percent, indicating a high proportion of new infections. As elsewhere in sub-Saharan Africa, adolescent women are more likely to be infected than their male counterparts. In total, up to 400,000 Rwandans are estimated to live with HEV, of which half are believed to have developed AIDS. Of those who are infected, roughly 50 percent are women and about 13 percent are children under fifteen. AIDS Epidemic and Gender Issues S .Theie-are. ,interconnected:gendler issuesat tihe core of the WiV/AIDS epidemic in Af6:a.:, -> Rigk faciors and rulnerability are substantially different for men and women, which reflecls physiological differences. ,ioquaities.ui Acces§sto economic assets, and lack of control of sexuality. The impact of the epidemic is falling-disproportionately on women, vwhid impIiesmtbal special care must be gixen to whom-preventive activities are directed and how they are carried out .;>.: Curbing the epidemic is a long-term process that hinges on b6th beha0ioralchange and gender dynamics. Sustained and responsible sexual behavior change will be possible through an expansion of economnic. opportunilies for women, promotion of women's rights and improsements in women's role in their communities and society. The political and social turmoil of the mid 1990s has altered and exacerbated the course of the epidemic and narrowed the gaps between rural and urban infection rates. HIV prevalence rates in rural areas rose rapidly from 1.3 percent in the mid 1980s to nearly 11 percent by the late 1990s, as the genocide triggered massive population movements, resulted in the rape of thousands of young women, and fostered high-risk sexual behavior in refugee camps. The increase in vulnerability and poverty (i.e. 60 percent of households are estimated to be below the poverty line in comparison to 40 percent in 1985) has provided fertile grounds for the EV/AIDS epidemic as individuals may be adopting more fatalistic behavior with regard to contracting a disease that takes years to develop. The disease has seriously eroded past gains in life expectancy (i.e. from about 50 in 1985-90 to 42 years in 1995-2000). By 2015, -5 - AIDS is expected in increase Rwanda's already high infant mortality rate by 10 percent (Rwanda and HIV/AIDS Country Profile, FBI, 1999). Annex 12 on the epidemiologic situation in Rwanda provides a more in depth review of patterns and trends in HIV/AIDS. Infant Mortality Rate With and Without AIDS 300 250 100 210 r _ _ > _ 50 -C0-With0Lt AIDS -0-G-With AIDS 0 19851990 1990-1995 1995-2000 2000-2005 2005.2010 2010-2015 SB--oe UNAIDS. 1953 Information from the recently conducted Behavioral Surveillance Survey (BSS) revealed generally high knowledge levels of HIV/AIDS but only sporadic use of condoms among the target groups surveyed (i.e. commercial sex workers, transport sector employees, young people, military). Nearly 80 percent of comnmercial sex workers were able to correctly identify two means of preventing HIV transmission but only 17 percent reported using condoms with all clients. A similar pattern was found among transport sector workers with reported knowledge levels over 92 percent but with only occasional use of condoms. Condom use was found to be particularly low among. young people, with only 10 percent reporting ever using a condom. The mean age of first sexual intercourse was found to be relatively low (i.e. 13 for boys and 14 years for girls), underscoring the importance of reaching young people at an early age. Over half of sexually active girls reported having an older partner, highlighting the economic vulnerability of young women. The 1998 Rwanda Sexual Behavior and Condom Use Study confirmed similar patterns of condom use and found continued stigma surrounding condoms, particularly by women. The rapid rise in HrV infection rates in paralled by a worsening TB epidemic. More than half of all Rwandan adults have latent TB infection. Global targets for TB control are to detect at least 70 percent of infectious cases and to successfully treat at least 85 percent of those cases. According to the WHO, the number of cases of TB reported in 2000 was 6,093, which represents only 29 percent of all TB cases in Rwanda. The National TB and Leprosy Control Programme (PNILT) reported a 67 percent treatment success rate in 1999. DOTS (Directly Observed Treatment Short-term), the WHO recommended TB control strategy, is standard in all districts with drugs provided at no cost to patients. Data correlating BIV infection and active TB in Rwanda are dated, but indicate that 40-95 percent of TB patients in different locations were co-infected with HEIV. The rural expansion of the HIV epidemic threatens to vastly increase the risk of TB for the entire population. Meanwhile, the low TB case detection rate suggests the existence of a large and expanding pool of infectious TB cases that are not yet being reached with DOTS. Rwanda's Global Fund proposal includes a promising strategy that will promote synergies between the TB program and the HIV testing and counseling networks, and ultimately offer life-extending opportunities for people living with HJV/AIDS by improving prevention, treatment and cure of TB. -6 - TB notifications in Rwanda T 7000 Estimated cases: 21,000 - 3 6000- 5000- 4000 - 3000 . 2000- i 1000- Z0- 1980 1986 1990 1995, 2000 Year *Polilical lurm,oil The government recognizes the devastating effects of the HIV/AIDS epidemic both at the household level and on the economy and society in general. Of immediate concern is the plight of vulnerable children. According to UNICEF, there are now an estimated 1 million orphans in Rwanda. Although the major cause of orphanhood was initially the 1994 genocide, AIDS has also made a substantial impact in recent years. By the end of 1997, a cumulative total of 94,000 children were thought to have lost either their mother or both parents to AIDS. Given the high HIV infection rates and relatively high fertility levels, it is estimated that 40,000 children are born to HIV-infected women annually and between 5,500-7,000 will become infected. -7 - Orphan & Community Depandant Children One of the lasting legacies of the 1994 genocide is the large number of orphans and vulnerable children who are now without adult protection and slipping through the social safety nets. While the government has made a tremendous effort to place unaccompanied children in extended or alternative family care the sheer magnitude of the problem and the widespread poverty in the country has taxed the capacities of communities to meet the needs of these children. According to a 2001 UNICEF study many orphans and in particular young children and child headed households are suffering from increased levels of social, economic and emotional marginalisation. Children under five are particularly vulnerable to the effects of inadequate care during these early years, as malnutrition, poor health, and limited stimulation adversely effect the ability to learn and function effectively, leaving serious long-term consequences for the individual and for society. According to the UNICEF study, the following issues were cited as most pressing by the children surveyed: grinding poverty which has been exacerbated by the loss of their parents: lack of access to education and vocational training; housing problems, psycho-social and emotional problems; exploitation in terms of labor and sex, which makes them increasingly vulnerable to HIV/AIDS; legal problems stemming from denial of their inheritance rights; and uncoordinated/inadequate assistance. Local authorities and administrators also raised concerns with the following issues: stigmatization of some categories of orphans, emerging tensions between children and their foster parents, brooder post-conflict social tensions, mistrust at the community level, which are impeding assistance to orphans and weak economic capacities of households. The consultative process has led to the following recommendations which are worthwhile supporting: (i) developing inclusive strategies in order to avoid risk of stigmatization; (ii) focusing initially on strengthening social networks and building cohesive community relations as a means for assisting children:: (iii) tackling policy and legal issues related to shelter, housing, access to education, medical services and inheritance rights; (iv) taking stock of all organizations working with orphans and assisting them to develop a long-term vision; and (v) strengthening institutional capacities with a particular focus on developing skills in social work, child development and psychosocial issues affecting children. Another major concern is the impact of the epidemic on the health care system. As in many other severely affected countries, the epidemic is having a severe shock on the health sector, as it fuels the demand for medical care and adversely affects the supply of care (e.g. absenteeism and mortality of health professionals, replacement costs, rise in utilization of health services). According to a recent study on The Impact of HIV/AIDS on Rwanda's Health Sector (January 2003) an estimated 5 percent of total outpatient visits may be attributed to AIDS patients and close to 4 percent of inpatient days may be due to PLWHA. This is a significant proportion considering that AIDS sufferers represent only .6 percent of the country's population. While there is little information on the direct impact on health workers, the same study estimated that the health sector might be losing annually as much as 1 percent of its workers due to AIDS with productivity losses of about 2.1 percent of all staff days. Finally, the study also raised concerns with the crowding out effect on non-AIDS related activities, citing results from various studies. One study found that AIDS patients have on average 11 ambulatory visits annually whereas the average Rwandan only makes .3 visits per year. An earlier study by Shepard and Bail (1990) estimated that AIDS patients at the reference hospitals in Kigali and Butare had an average length of stay of 25 days, twice as long as that of a control group. Finally, it should be noted that the total number of hospital beds occupied by those living with HIV/AIDS rose from 9,000 in 1993 to 35,600 in 1997 and that by 1997, 21 percent of all pediatric patients and 60 percent of those presenting with malnutrition problems in the Kigali Central Hospital were HIV-positive. -8 - Government Response Since the emergence of the first AIDS cases in the mid 1980s, the government of Rwanda has been proactive in implementing a series of national plans, demonstrating strong commitment and leadership in the fight against the epidemic. Each medium-term plan has been characterized by an intensification of the scope and range of interventions. The First Medium Term HIV/AIDS/STI Plan (1988-92) carried out by the Rwandan National AIDS Control Program (PNLS), focused on blood transfusion safety, health education and epidemiological surveillance. The Second Medium Term Plan (1993-97) continued with preventive activities while giving an increased focus to minimizing the socioeconomic impact of AIDS on those infected or affected. In 1997, the government adopted a multi-sectoral, decentralized approach, giving increased responsibility to health districts. The Third Medium Term HIV/AIDS Plan (1998-2001) was more ambitious in scope and was developed in a participatory manner. In March 2001, the government established a high-level coordinating body (Commission National de Lutte Contre le SIDA, CNLS) in the Office of the President, providing greater visibility to the program. Provincial committees have been created and all have now prepared first year action plans for financing by the MAP and other development partners. Plans are underway to make fully operational the district and conmnunity level committees. The recently released 2002-2006 Strategic Plan for HIV/AIDS constitutes a sound basis for IDA support under the Multi-Country HIV/AIDS Program (MAP) for Africa, focusing on prevention, care & treatment, and mitigation. The plan is in conformity with internationally accepted standards. It places a special emphasis on vulnerable groups, such as refugees, widows, demobilized soldiers and prisoners. Interventions targeted to these groups are being supported through various operations, including the MAP. The plan was prepared in a participatory fashion with country-wide consultations involving a broad spectrum of Rwandan society (e.g. public officials, and representatives of NGOs, PLWHA, church groups, youth clubs, women's organizations and private sector groups). The specific priorities and strategies in the plan are to: (i) strengthen preventive measures by promoting multi-sectoral IEC activities, expanding availability of VCT services, promoting condom utilization, reinforcing STI management, ensuring security of blood transfusion, and preventing mother to child transmission (PMTCT); (ii) expand care and treatment by providing psycho-social and medical support to affected individuals and families; and (iii) carry out supportive activities, including research, training and capacity building, and enhanced coordination. The total cost of the five-year program is tentatively estimated at roughly US$69 million. The proposed IDA grant represents about 44 percent of the funding of the five-year program. In November 2002 the government established a new position of State Minister in charge of HJV/AIDS and other infectious diseases within the Ministry of Health, in order to ensure that concrete and focused actions are taken. The Ministry of Gender and the Advancement of Women (MIGEPROFE) has been proactive in promoting changes in gender-discriminatory legislation and in supporting the enactment of gender-responsive legislation, as spelled out in the 'Comprehensive action plan for the elimination of all discrimination against women (1999). This ministry has made a huge effort to improve understanding of discriminatory practices, including socio-cultural barriers to family planning and legal barriers to land tenure, which raise the vulnerability of women. The inclusion of Rwanda in the first round of grants from the Global Fund for AIDS, TB, and Malaria (GFATM) augurs well for the national program. Rwanda has been awarded about US$14 million to establish a national network of voluntary counseling and testing (VCT) centers which will provide an integrated package of care, as noted below. VCT is viewed as an essential ingredient for bringing about behavior change and as a key entry point for care and support of the infected. To address the growing demand for VCT services, the goal is to set up three VCT centers in each district for a total -9- of roughly 117 sites, from the current number of about 30. While these plans are extremely ambitious, the model represents a promising way to build synergies between prevention, care and treatment. Rwanda's Global Fund Proposal: Integrated VCT Model V VCT service that includes confidential & individual counseling and rapid & anonymous testing. V PMTCT, integrated at the health center's antenatal site with links to the VCT service for testing and to other health center services, such as nutritional support and training. / Treatment of opportunistic infections. D Diagnosis and treatment of STIs using the syndromic approach. V Links between TB and VCT services to encourage TB patients to be tested for HIV at the VCT site. V Links between the health center and home-based care and psychosocial support being implemented by community-based associations. V Supportive IEC activities. While significant progress has been made, the impact of past efforts has been limited with the epidemic continuing unabated. This is due to a combination of program-related issues and external factors. The national program has faced both financing problems and severe capacity constraints, stemming in part from the tragic events of the mid 1990s. While reported knowledge levels have improved substantially, there are still large gaps between knowledge and behavioral change with condom utilization rates remaining relatively low. General weaknesses in the health system have resulted in limited progress in strengthening treatment of STIs, which are key to controlling the epidemic. There are also weaknesses in the supply chain management for the delivery of HIV/AIDS commodities that will need to be addressed by strengthening capacities to forecast needs, and to procure and distribute commodities. Moreover, financial barriers to accessing health services remains a key concern, particularly for the most vulnerable groups. Finally, there are huge challenges related to de-stigmatizing the illness, improving acceptance of PLWHA, and tackling gender issues which are at the roots of the epidemic and have been exacerbated by the trauma and internal disruption of the genocide. Eligibility for MAP The Government has requested IDA resources within the framework of the second phase of the Multi-Country HIV/AIDS Program (MAP) for the Africa Region which was presented to the Board of Directors on December 20, 2001. Following a September 2002 meeting of the Board of The World Bank, Rwanda is now eligible for MAP funding on a grant basis, as the governors have approved an expanded programnme of grants under the IDA 13 replenishment. Rwanda has satisfied the MAP eligibility criteria, as follows: 0 Satisfactory evidence of a strategic approach to HIVIAIDS Rwanda has produced a comprehensive, multi-sectoral HIV/AIDS strategic plan in a participatory manner. Consultations with representatives of government institutions and civil society took place in all provinces. - 10 - * Establishment of high-level HIVIAIDS coordinating body In March 2001, a National HIV/AIDS Commission (CNLS) was created under the Presidency of the Republic. The President has been strongly involved in the fight against the epidemic. The coordinating body includes representatives of both government agencies and civil society organizations. It is responsible for: (i) elaborating policies and strategies; (ii) coordinating multi-sectoral activities; and (iii) mobilizing internal and external resources. Efforts are underway to decentralize the HIV/AIDS program operating through the provincial, district and community EHV/AIDS commissions. * Agreement to use appropriate implementation arrangements The Government has established a Secretariat to coordinate the national program under the CNLS. It is in the process of establishing a Project Management Unit dedicated to the MAP within the CNLS. The government has agreed to outsource some activities, such as behavioral surveys and operational research but favors retaining the procurement and financial management functions within the project unit. The Bank has agreed to these interim arrangements that would be evaluated at the end of the first 18 months to determine their effectiveness. The criteria against which these transitional-arrangements will be assessed were finalized during negotiations and incorporated into the minutes of negotiations and Annex 11. * Government agreement to use andfund multiple implementation agencies The Government has agreed to fund activities undertaken by both public and private sector groups (e.g. civil society associations, religious groups, private firms). Resources will be transfered to these groups on a grant basis, building on the relatively successful experience under other IDA-supported operations. 3. Sector issues to be addressed by the project and strategic choices: While the HlV/AIDS program in Rwanda faces numerous challenges the IDA operation will deal selectively with a number of key issues. The goal is to complement activities to be supported by Rwanda's other development partners, especially the major initiative of setting up the national network of VCT services that is funded by the Global Fund. To this end, three major issues will be addressed by the project: * Weak implementation and institutional capacities Capacities to mount and sustain effective efforts to control the HIV/AIDS epidemic in Rwanda are modest. The genocide and war of the mid 1990s resulted in a massive loss of health and other professionals, as many were killed or forced to flee the country. While the government has made a tremendous effort to rebuild its human capital and strengthen institutional capacities much remains to be done. All major public sector institutions that will lead the fight against the epidemic need to be reinforced. These include the Secretariat of the National HIV/AIDS Commission (CNLS), the Treatment and Research AIDS Center (TRAC), which is the arm of the Ministry of Health responsible for biomedical aspects of prevention and care, the provincial and district HIV/AIDS committees, as well as line ministries that are expected to increasingly be involved in behavioral change. Capacities are also limited in the private sector and amongst civil society groups, particularly in terms of elaborating solid proposals, monitoring results, and managing funds. * Need to strengthen partnerships with civil society Non-governmental organizations, church groups, women's associations, community groups, and youth organizations have demonstrated their ability to play an important role in prevention, care and support. Many of these groups have good track records but often work with relatively small numbers and in geographically limited areas. The Rwanda MAP will provide these organizations with financial and technical assistance to introduce or scale up promising approaches, rather than define up front a narrow set of activities to be funded. The project will build on models for funding community groups and NGOs that were successfully developed and implemented under earlier projects in Rwanda (e.g. HIV/AIDS component of the Health and Population Project and the Community Development and Reintegration Project) to pilot and then scale up modalities for channeling grants to these groups. n Financial barriers to accessing health services With over 60 percent of the population estimated to fall below the poverty line, special attention needs to be given to financial barriers to health care, particularly as HIV/AIDS has a crippling effect on household finances of the afflicted. According to an analysis of national health accounts data, households with seropositive members face staggering medical costs. Out of total spending on H[l prevention and treatment in Rwanda, household out-of-pocket expenditures make up 93 percent, donor contributions 6 percent, and government financing 1 percent. The distribution of funds, by type of expenditure, revealed a heavy emphasis on care and treatment with close to 80 percent of all resources devoted to treatment of opportunistic infections and 14 percent for antiretroviral treatment. The same household survey found that out of the 348 low-income households interviewed, 73 percent were either unable or met with difficulty their food needs. Other research has shown that reintroduction of fees in 1996 lowered utilization of health care services by the poor except in districts that had established community health financing schemes (mutuelles), suggesting that subsidies to enable consumer access to these schemes may be a way to address financial constraints on the demand side. This implies that particular attention needs to be given to demand-side constraints in addition to strengthening the delivery of services. To this end, the project will support piloting of demand-side interventions aimed at providing affected individuals and households support to cushion the shock from the effects of this catastrophic illness. This would consist of supporting the relatively successful pre-payment schemes, financing of micro-projects that include targeted subsidies, direct financial transfers to health districts or other demand-side subsidies. 4. Program description and performance triggers for subsequent loans: N/A C. Program and Project Description Summary 1. Project components (see Annex 2 for a detailed description and Annex 3 for a detailed cost breakdown): The proposed project will support the implementation of the 2002-2006 HIV/AIDS National Strategic Plan. It includes four components: (1) public sector support; (2) FRV/AIDS care and treatment; (3) civil society support; and (4) program management, monitoring and evaluation. The design of the project has taken into account the difficult post conflict environment in Rwanda by: (a) planning for a longer than average implementation period to reflect the limited absorptive capacities in all sectors; (b) proposing a phased approach, whereby the initial years focus on working with organizations which have a proven track record and/or already have work plans ready for financing while assisting other organizations to strengthen their capacities; and (c) placing a strong emphasis on capacity building at all levels in both the public and private sectors by 'mainstreaming' these activities (rather than having a separate component), which is expected to be most effective in this resource constrained environment. Activities funded under the four components will be prioritized and sequenced in order to ensure that investments to strengthen capacity are initiated early and so that project activities complement intiatives funded by others. For the public sector, activities would be phased by starting with the line ministries which already have their work plans ready and have considerable experience. For the civil society component, the phasing would be done by also begining with those large organizations which have a good track record and solid experience. The CNLS would carefully monitor the initiation and - 12 - progression of capacity building efforts for all public sector and civil society organizations. To the extent that this operation has been developed to complement and fill-in the gaps with regard to the Global Fund, phasing of investments will occur according to the government's expansion plan for the integrated VCT sites, particularly for the care and treatment component. As in other MAP operations, Rwandan authorities will have the flexibility to allocate funds across these components, depending on the performance of different stakeholders, as documented through annual reviews. Component #1: Public Sector Support (US$7.0 million) The purpose of this component is to initiate, facilitate, and/or support the mainstreaming of HIV/AIDS activities into line ministries and other public sector institutions with a view to bringing about desired changes in both individual and institutional behavior. All line ministries and public sector institutions would be eligible for project financing based on a satisfactory review of their annual work plans. The Rwandan public sector is expected to play a leadership role in terms of setting strategic directions and providing information. The project will support the building of capacity within line ministries and the implementation of HIV/AIDS work plans to assist the public sector in fulfilling this mandate. A number of line ministries in Rwanda are already engaged in the fight against HIV/AIDS in their respective sectors and will benefit from project support to strengthen and scale up their programs. The Ministry. of Health is playing a lead role in the Rwandan response, focusing on the medical and public health aspects of the epidemic. The Ministry of Defense is supporting IEC/BCC activities, condom promotion, and STI and VCT services. The Ministry of Education has been introducing HIV/A]DS information into schools at the end-primary and secondary levels, and is supporting the establishment of anti-AIDS clubs. The Ministry of Youth is supporting IEC/BCC and reproductive health services, especially for young women. The Ministry of Local Government is beginning to provide materials and nutritional support to orphans and vulnerable children. ORINFOR, the Rwandan Information Office, has been active in the dissemination of EEC messages through radio programs. The Ministry of Gender has plans to integrate HIV/AIDS themes into non-formal education programs targeted to vulnerable women. GLIA, an agency set up to address regional HIV/AlDS issues, is also initiating activities which would benefit from the project, including support for advocacy and policy coordination in the Great Lakes region. The Government has elaborated an approach for sector-specific responses to the HIV/AIDS epidemic in the National Strategic Framework and Multi-sectoral Plan, which includes both capacity-building activities and sector-specific responses. Capacity-building aspects will be particularly relevant for those line ministries not previously considered to have a direct role in combating HIV/AIDS. The capacity-building aspects will include support for assessments that would provide a clearer understanding of the HIV/AIDS impact both within the ministry and its client population, and also provide guidance in the development of appropriate responses in terms of both content and scale. Line ministries will be expected to address the manner in which HIV/AIDS has affected their ability to provide services in their respective sector, planning and management of sector resources, human resources policies, and financial support from both government and donors to mitigate the impact of the epidemic. While the impact of the epidemic will differ across sectors, many issues will be common. Thus, work plans of line ministries will support the following broad categories of activities: Capacity Building, Planning & Policy * Conduct sector impact assessments focusing on target groups. * Strengthen policy formulation with regard to HIV/AIDS with a focus on: (i) benefit packages for staff and dependents on long-term care for this catastrophic, high cost illness; (ii) policies ensuring protection of human rights for PLWHA and minimizing discrimination in the workplace; and (iii) - 13 - gender-specific policies and programs affecting both ministry staff and populations served. O Train staff in preparation, execution and monitoring of work plans. Prevention, Care, and Support Services o Information/education/communications (EC) and behavioral change communications (BCC) campaigns targeted to ministry staff and their constituencies. O Promotion of condoms within ministry offices at national, provincial, and district levels. O Distribution of information regarding available health and social benefits to HIV-positive individuals. o Distribution of information regarding available health and social services, including location of VCT sites. o Support mainstreaming of gender issues related to HIV/AIDS. Component #2: Health Sector HIV/A]IDS Care and Treatment (US$10.9) The project will support the implementation of work plans prepared by the Ministry of Health, which would be carried out through public/private partnerships, to provide complementary support to funds received from the Global Fund and from other development partners. More specifically, the project aims to strengthen: (a) Diagnosis, care and treatment of HIV/AIDS patients, including sexually transmitted infections, opportunistic infections and tuberculosis. This will include: (i) improving capacity among health professionals at all levels, by supporting an integrated program of in-service and on-the-job training on HIV testing techniques, diagnosis and treatment of opportunistic infections, AIDS case management, syndromic and laboratory diagnosis of STIs, home and community-based care, blood and injection safety, logistics management, and counseling skills; (ii) providing essential drugs and related diagnostics to treat HIV/AIDS-related opportunistic infections and STIs and to deliver antiretroviral therapy; and (iii) carrying out minor rehabilitation/refurbishing of sites which will serve for the provision of treatment of Ols, STIs, TB. reproductive health, family planning and antiretroviral therapy. (b) Prevention of mother-to-child HIV transmission by supporting the national PMTCT program, as required to complement the integrated VCT service delivery model, through the provision of training, technical advisory services, acquisition of medical equipment, and minor rehabilitation/refurbishing. (c) HIV voluntary testing and counseling services, through the provision of complementary support to that provided by the Global Fund, with a particular focus on remodelling/refurbishing of health centers to allow for the provision of confidential and user-friendly VCT services. (d) Technical capacity of laboratories and blood banks to improve HIV testing and counseling and diagnosis and monitoring of patients, including through the procurement of reagents, laboratory equipment, logistical support and basic supplies, particularly for district hospitals. (e) Sentinel surveillance and support operational research: The project will include support for strengthening sentinel surveillance through the provision of reagents, staff training, and acquisition of computers and for a number of priority operational research studies related to the more effective clinical management of HIV/AIDS, STIs, OIs cases and the feasibility of expanding ARV therapy. (f) Handling and disposal of HIV/AIDS infected materials, in line with the strategic orientations of the waste management plan, including financing of training, technical advisory services, equipment, and supplies. - 14- Component #3: Civil Society Support (US$10.7 million) In order to engage and empower civil society organizations in the national response, the Rwanda MAP will support HIV/AIDS work plans of community groups, youth groups, women's groups, associations of People Living with HIV/AIDS (PLWHA), non-governmental organizations (NGOs), religious groups, labor unions, and private enterprises. Community-driven local initiatives, funded through these grants, will contribute to the improvement of the welfare of communities by increasing their access to resources to prevent further spread of HIV and to address the impact of the epidemic on individuals and households. These sub-projects will be prepared, implemented, and managed by beneficiary communities and stakeholders. These organizations will be encouraged to focus activities on key target groups, such as orphans and vulnerable children, widows, and youth. The FHV/AIDS community grants will include the following types of activities: * Preventive measures to facilitate behavior change, including peer programs, theatrical productions, social marketing of condoms through conmmunity based distribution (CBD) schemes, informal education programs for out-of-school children, awareness and mobilization activities to be supported under the youth groups against AIDS (FOJAS), and lEC messages to be disseminated by faith-based groups. * Social and financial support for orphans and vulnerable children who will be a key target group to be supported under this component. Financial support will be channeled to organizations to finance school fees and related expenses, access to health services, income generating activities for the older youths, and pscyho-social support. A child needs assessment is currently being carried out as part of project preparation by a number of NGOs. The goal is to use this tool to assist NGOs and community groups to identify the needs of young children affected by the epidemic in their respective communities and to design appropriate sub-projects to be scaled up under the MAP. Annex 14 describes the approaches and strategies to be used in scaling up these interventions. * Psycho-social & trauma counseling targeted to vulnerable groups who have been traumatized as a result of the genocide and are experiencing psychological disabilities with a particular focus on women. * Training programs for community volunteers, counselors, and home based care-givers. * Support to associations of PLWHA, in addition to seed funding to start income-generating activities to those infected or affected by HIV/AIDS. * Support demand-side subsidies to address the financial obstacles faced by poor people seeking testing, care and treatment for opportunistic diseases associated with fHV, PMTCT, and for eventual ARV treatment as it scales up. Demand-side financing could be in the form of vouchers to cover fees for testing or drugs, or partial/complete subsidies for poor families to join the community financing pre-payment schemes (mutuelles). A study (see box below) will be undertaken to guide the design of these types of interventions which will be subsequently piloted and assessed during the first two years of the project. The civil society component will be implemented through two modalities. The first will involve an 'on-granting' arrangement, whereby an NGO with substantial capacities and a strong track record will provide sub-grants to smaller NGOs and associations to strengthen and/or scale up their activities. The second modality will consist of supporting cross-cutting community HIV/AIDS initiatives under the guidance of local Community Development Committees which would work hand in hand with the CPLSs and CDLSs. These modalities will be tested during the initial years and scaled up depending on results attained. The details of these arrangements are described below under the institutional and implementation section (Section 4). -15 - Component #4: Program Management, Monitoring, and Evaluation (US$3.4 Million) Program Management, Coordination & Capacity Building This component will provide financial and technical support to the National H[V/AIDS Commiission (CNLS) to coordinate the national program, as well as the project activities. It will also provide support to the provincial (CPLS) and district-level entities (CDLS) to assist them to coordinate local activities, carry out advocacy and facilitate social mobilization. This will involve the provision of technical assistance, training and operating support to complement funding to be provided by the government. The phasing of these activities at the decentalized level will occur according to a set of readiness criteria agreed upon with the government team and to be spelled out in the operational manual. The component will also support activities that are to be coordinated centrally by the CNLS, which involve economies of scale. This may include organization-of training workshops and capacity building activities for CPLS, CDLS, NGO/CBOs, representatives of line ministries, and other key stakeholders; carrying out national IEC campaigns; developing requisite guidelines, and other activities necessary to coordinate and stimulate the national response. The CNLS may also commnission studies on topics of special interest such as how to promote income generating activities and how to strengthen home-based care of patients. Monitoring & Evaluation CNLS, in collaboration with its partners, will be responsible for the overall monitoring and evaluation of program progress. The project will support, as necessary, activities to strengthen the monitoring and evaluation of the program, drawing on recommendations of technical assessments carried out with support from the USAID-funded MEASURE Project. This could include financial and technical support for: carrying out staff training, carrying out studies and surveys (e.g. Demographic and Health Survey, Behavioral Surveillance Survey, Beneficiary Assessments, IP6/IP7, Child Needs Assessments), and organizing workshops to disseminate results. Project Coordination This component will also provide support for the establishment of the Project Management Unit, in order to facilitate the programming, coordination and monitoring of project activities. To this end, the project will support the recruitment of skilled and experienced staff to the PMU, technical and financial audits, logistic support to facilitate coordination and monitoring, and the organization of meetings of the steering committee and annual project reviews. l_ ; -. t _J; _ Indicative Bank- %of - l " r ' ComponentL-=- - ; - - : - - = 5 Costs %of financing Bank- (US$M) Total (USSM) financing - Public Sector Support 7.00 21.9 6.31 20.7 - Health Sector HIV/AIDS Care and Treatment 10.87 34.0 10.60 34.8 - Civil Society Support 10.72 33.5 10.61 34.8 - Program Management, Monitoring and Evaluation 3.41 10.7 2.98 9.8 Total Project Costs 32.00 100.0 30.50 100.0 Total Financing ]Required 32.00 100.0 30.50 100.0 2. Key policy and institutional reforms supported by the project: The project will indirectly support the decentralization policy by building capacity of local communities and authorities to better manage the HIV/AIDS epidemic. It will also support, as necessary, reform of policy and legal framework aimed at assuring the rights of orphans and widows who are some of the most vulnerable groups. - 16 - 3. Benefits and target population: The proposed project would contribute to slowing the spread of the HIV/AIDS epidemic and to alleviating the burden on individuals and households. It is expected to have multiple benefits. First, by slowing the rate of new BHIV infections it would reduce the number of new AIDS cases that would appear in the future, and reduce the consequent medical and social costs, human suffering, and financial burdens on families. Second, the project would improve the quality and extend the lives of PLWHAs, most of whom are in their peak productive years. Infected individuals are expected to have improved access to palliative care, treatment of STIs and opportunistic infections as well as psycho-social support to better cope with the illness. Thirdly, important externalities would accrue to society in terms of direct (e.g. lower treatment costs) and indirect cost savings (e.g. lower productivity, savings and investment losses, reductions in the number of new orphans). It should be noted that Rwanda has a unique opportunity to turn the tide of the epidemic and avoid a dramatic escalation of costs which has been experienced by other countries with more advanced HIV/AIDS epidemics. For example, in countries in southern Africa where HIV prevalence rates have reached 30 percent, annual costs of dealing with prevention and care can be as high as 10 percent of GDP, as can be seen from the figure below (Costs of Scaling HIV Program Activities to a National Level in Sub-Saharan Africa: Methods and Estimates, ACTAfrica, The World Bank, November 2000). Finally, the project would allow Rwanda to better equip itself to manage the epidemic in the longer term. Particular benefits would accrue to the most vulnerable groups through targeted interventions aimed at reaching youth, women and their newborns, orphans and high-risk groups (i.e. commercial sex workers, transport sector workers, military). Per Capita Costs of Scaling-up Prevention Care and Care and HIV Prevalence Rates 15 0 10 0- 0 0 0~~~~~~~ Cd 0 0 0 / 0 0 0 0 O~~~~ 0 V 5~ - 2'o ° U 000 0 0 10 20 30 40 Adult HIV Prevalence Rate -17 - 4. Institutional and implementation arrangements: Institutional arrangements State Minister in charge of HIV/AIDS and other infectious diseases The government of Rwanda has recently appointed a State Minister in charge of HIV/AIDS and other infectious diseases within the. Ministry of Health. According to a November 25, 2002 presidential decree, a State Minister was appointed by the President of the Republic. The State Minister is expected to have the following responsibilities with regard to HIVIAIDS: (a) implementing the policy of the government as proposed by the CNLS and as expressed by communities; (b) supervising and evaluating the implementation of the policy; (c) proposing updates and adaptation of the policy to the government; and (d) coordinating all actions in relation to HIV/AIDS at the political level. The Ministry of Health, through the State Minister, will be the 'tutelle' ministry for this multi-sectoral HIV/AIDS operation, representing the project's interests at the highest level of cabinet and Parliament. It will not be involved in the daily management Qf the project. The government has spelled out these arrangements in the operational manual for this operation. National HIV/AIDS Commission (CNLS) The Government of Rwanda has established an institutional framework that reflects the multi-sectoral nature of the national HIV/AIDS program and facilitates the establishment of effective partnerships for a concerted and decentralized response to the epidemic. Pursuant to Decree No. 02/01 of March 16, 2001, the CNLS was established in the Office of the President and was entrusted with: (i) formulating national policies and strategies; (ii) coordinating action plans of various stakeholders; (iii) raising awareness and conducting advocacy; (iv) mobilizing financial resources both inside and outside Rwanda; and (v) maintaining political support and commitment at the highest levels of government. The commission is comprised of an Executive Secretary and up to 20 commnissioners, including ministers of key portfolios (i.e. health, social affairs, planning) and representatives of civil society. Members are appointed by a presidential order endorsed by cabinet. They are appointed for a renewable 3- year term based on past performance. The Coordination Committee is made of up of a chairman, two vice-chairmen and an excecutive secretary. The first vice-chairman is the State Minister in charge of H1V/AIDS and other infectious diseases. The second holds the social affairs portfolio. The secretariat is held by the Executive Secretary who is responsible for the execution of the CNLS program. The Management Committee meets twice a month, while the Assembly of Commissioners meets once a month. The Commission invites others to participate in selective discussions but they would not have any decision making capacities. Multisectoral Sub-commissions Three sub-commissions have been created within the CNLS: (i) Planning and Coordination; (ii) Social Mobilization; and (iii) Monitoring and Evaluation. These sub-commissions operate closely with respective directorates of the CNLS Executive Secretariat and report to the General Assembly of Commissioners. Each sub-commission is composed of at least 5 CNLS members plus the respective director. Technical experts and groups are invited to attend the sub-commission meetings whenever necessary. Executive Secretariat The Executive Secretariat is the administrative and technical arm of the CNLS. It is headed by the Executive Secretary and composed of 4 directorates: (i) Administration and Finance; (ii) Planning and Coordination; (iii) Social Mobilization; and (iv) Monitoring and Evaluation. The Secretariat will be equipped with full-time contractual staff specialized in the areas of HIV/AIDS, training, monitoring & evaluation, financial management and accounting, and procurement who are - 18 - selected on a competitive basis. While the government has begun the process of establishing the CNLS it will need to accelerate the recruitment of staff to fill key positions in order to mount an effective national response. The CNLS organizational chart is presented below: I CDLCie MironAnisry of HelhTeMnsryofw Healthp wilcntnurpayigapvtlrlei h eia ! hiclersg s o o a r, , and d~~~~~~~~~~~~~~~~~~~~~~~~~~ I I eRrr Scal . :>cS,. remodelling of facilities supported through the public sector component for provision of preventi.on, treatment and care though the decentralized health system. This will involve coordination with CNLS, TRAC and CAMERWA on procurement of drugs and medical supplies. * Logistics management and distribution: oversight of the distribution and logistics mranagement for drugs, equipment and supplies through the public sector component for treatment and care. * Standards, clinical guidelines, treatmnent protocols: preparation, dissemiination and training in I _ . . 0 ~~~~~~~- 1-. standards, clinical guidelines and protocols for treatment and care supported through public sector component. O Quality and performance improvement: maintenance of quality standards and introduction of performance improvement measures for treatment and care supported through the public sector component. o Coordination with other ministries: coordination with other ministries on the above to ensure that information regarding available health and social services is readily available to staff of other ministries. O Holistic approach to treatment and care: ensuring that standards and protocols for HIV/AIDS prevention, treatment and care supported under the public sector component are harmonized with standards and protocols for other public health priority areas (e.g. reproductive health, communicable diseases, nutrition) to achieve a holistic approach that addresses the health needs of clients at all levels of the decentralized health care system. o Personnel management: elaboration of position descriptions for consultants to be recruited to strengthen prevention, treatment and care of HIV/A1DS clients; support of staff training; and deployment and performance management for staff supported under the health sub-component of the project. Implementation Arrangements Project coordination The Executive Secretariat of the National HIV/A1DS Conmnission will have the overall coordinating and management responsibility for the project and will be accountable for its success. A Project Management Unit (PMU) is being established within the Executive Secretariat of the CNLS to handle the day-to-day management of this operation. It will be independent and have full autonomy to take decisions on all matters, in conformiity with the policies and strategies established by the CNLS, which has the ultimate responsibility for policy formulation, according to Presidential Decree No. 02/01 ( March 16, 2001). The PMU will be responsible for: (a) facilitating the design, approval and monitoring of annual work plans and budgets of various stakeholders; (b) handling procurement, financial management and disbursements; and (c) monitoring and reporting on project activities. The PMU will be headed by a Project Manager who has solid experience in the coordination of operations of this size and complexity. Experience in program planning, coordination of multi-sectoral tasks, and handling large numbers of stakeholders are essential. The PMU will include a core staff consisting of a project manager, procurement specialist, financial management specialist, and three program officers (i.e. public sector, civil society, monitoring and evaluation). A selection panel will be established for the recruitment of key personnel who will be hired through a competitive process. The selection panel will consist of a subset of the steering committee as well as a representative of the National Tender Board, in order to ensure transparency in the process. A project steering committee will be established to provide oversight, guidance and advice. As a consultative body, the Project Steering Committee will be composed of the Executive Secretary (chair) and representatives of the office of the President, State Minister in charge of HIV/AIDS and other infectious diseases, Mvinistry of Health, Ministry of Finance, private sector, NGO/religious organizations, and the Project Management Unit. The steering committee will review and advise the CNLS on the approval of annual work plans and progress reports; provide advise on strategic directions; and assist to resolve major problems. Work plans and progress reports will be subsequently presented to the CNLS for approval. The Executive Secretary of the CNLS will organize the steering committee meetings, to be -20 - convened at least twice a year and to be chaired by the Executive Secretary. A project approval committee will be established to screen and approve action plans under the MAP operation. This committee will be headed by the Executive Secretary. It will be comprised of the following members: Director of Finance and Director of Planning and Coordination of the CNLS; Project Manager, and representatives of the Ministry of Health, Ministry of Finance, public sector and civil society (i.e. PLWHA, NGOs, and faith-based organizations). The specific lines of responsibilities and accountabilities of the key stakeholders and the relationships between them are spelled out in an operational manual and are illustrated below. National Coordinating Structures by Sector (Public, Private, and Community-based Organizations) fl r t | ~~~~~~~~~~~~~COMMUNITY SECTR _ HIV/AID5 _ PRIVATE SEC OR ~~~~~~~~~ORGANIZATIONS CONMMrrEE _ INTERNINISTEFtIL ._ EIRPtE _(IC COUMITTEE (CIM E CWNTERP(CISE) Sectoratl Sectoral Enterpiises Eniterpises -Hl V/AIDS Sb HI V/AIDS HIV/AIDS Sub- HIV/AIDS Comrmittee Committee Associaion Association SSub-S,oer S.co, Comn&tIue- Sob-S,dor (MsSiinisry) (Ministry) Committee Committee CNG0 Loeol Qo.boh,o Orgoooitierm Cotrnuue Assocooti s tRdigioo Sia } Enlerpitse | l s~~~~~~~~~~~~~~~~~~~~~~~~mit | Hlv/AIDS CeD | | Entprise l lMV/AH) l IIAD c rlADell l lris CDLS Implementing Agencies Activities funded under the project will be implemented by public and private organizations in a phased manner starting with line ministries, NGOs, and associations which already have HIV/AIDS work plans and a proven track record in managing activities and funds. Coverage will be extended to other stakeholders as their implementation capacity is strengthened and their work plans are ready. (a) Line ministries & other public sector organizations On the government side, public entities at the national, provincial, district, and local levels will prepare funding proposals. These will be - 21 - consolidated annually by line ministries in a work plan and budget. Sectoral focal points, involving representatives of government institutions and private organizations, have already been established for many line ministries and will be established in others to spearhead development of the respective sector strategies and promote implementation of work plans. The focal points will validate proposals to ensure their conformity with sectoral strategies, monitor implementation, and report to CNLS on progress. The CNLS will review and approve the annual work programs and budget proposals of line ministries and other public sector institutions and subsequently submit them to the PMU that will be responsible for contract preparation. A Memorandum of Understanding (MoU), including the work program and budget along with a set of performance indicators will stipulate what will be done and what results are expected. The funds that line ministries receive from the project will be complemented with contributions from line ministry budgets to esure that adequate resources are put at the disposal of all stakeholders. The following line ministries have been identified as priority sectors for the Rwanda MAP: (i) Ministry of Health, (ii) Ministry of Defense, (iii) Ministry of Youth, Sports and Culture, (iv) Ministry of Local Administration and Social Affairs, (v) Ministry of Interior, (vi) Ministry of Gender and Women Promotion, (vii) Ministry of Finance and Economic Planning, and (viii) Ministry of Labor and Civil Servants. Line ministries will develop and implement plans through their existing provincial, district and community levels to facilitate a decentralized response to the epidemic. Given the level of preparation of various ministries and the availability of funds from other sources, during the first year of the project the focus will be on the following ministries: health, defense, youth and local government. During the initial years, the remaining ministries will have access to technical and financial assistance to assist them to carry out their situation analyses and to prepare their annual work plans. (b) Provincial & District HIVIAIDS Commissions (CPLS, CDLS) The CPLS have been established in all 12 provinces and are slowly getting off the ground. These commissions are expected to take off after an intensive capacity building effort. These provincial bodies are composed of civil servants and representatives of civil society, including women, youths and PLWHA. The CPLS are responsible for advocacy, social mobilization, and coordination of H1V/AIDS activities in their provinces. About 106 district HIV/AIDS commnissions (CDLS) have been established to carry out similar functions at the district level. (c) Civil Society The civil society component will be implemented through two different modalities that will be piloted and gradually scaled up. Depending on experience, which will be reviewed at the end of the first two years, these modalities will be expanded during years 3 to 5 of the project. O On-granting The first will involve an "on-granting" arrangement, whereby organizations that have the technical expertise in capacity building and substantive content, and who have a track-record in working effectively with grass-roots civil society groups in Rwanda will be solicited by the CNLS to submit proposals, explaining how they will manage the on-granting arrangement and the types of organizations and content areas that they plan to support in accordance with the strategic priorities in the 2002-2006 HIV/AIDS Plan. The CNLS will select up to three on-granting organizations during the first year and gradually increase the number in subsequent years depending on perfonnance. The on-granting organizations will benefit from technical assistance from a national or international NGO in order to ensure a coordinated and consistent effort. Parallel funding to the MAP is being sought for this purpose. Alternatively, if this technical assistance can not be secured the government will use project funds for this purpose. The three on-granting organizations will be responsible for screening proposals, providing assistance to organizations that apply for small grants, providing oversight, and handling technical monitoring and financial management, including program and financial reporting. Each organization will set up a selection/oversight board consisting of its own key staff, representatives from civil society and government. The amount for each "on granting" arrangement will be around US$150,000, of which 85 percent will be used for sub-grants up to US$15,000 with 15 percent of funds allowed for administrative costs. The details of these arrangements are spelled out in the operational manual. * Community sub-projects The second, parallel channel will build on the experience of the IDA-funded Community Development and Reintegration Project (CDRP), which was successfully piloted over the past three years and which will be scaled up in a second phase. The preparation of this follow up operation is running more or less on a parallel track to the MAP operation. The advantage of this model is that the procedures and mechanisms for channeling resources to communities already exist and have a proven track record. Moreover, the use of a bottom up, participatory process of analyzing problems, identifying solutions and designing interventions on this basis is very much in line with the HIV/AIDS approach to empowering communities. Under this model, cross-cutting community HIV/AIDS initiatives will be funded under the guidance of local Community Development Committees (CDCs) working with community and district HIV/AIDS Commissions. Supplemental funding will be provided under the MAP to enable Community Development Committees (CDCs) to identify, fund and monitor implementation of such initiatives. An operational manual for this program has already been developed and will be adapted for the added support of HIV/AIDS initiatives. This approach will be pilot tested during the first two years in the districts supported under the recently completed CDRP operation at a level of about $100,000 each and scaled up in years 3-5 of the project, depending on results attained. Operational Manual An Operational Manual has been prepared with financial support from a grant provided by the Japanese government for the preparation of this project. The manual was adopted by the government and submitted to the Bank in February 2003. The manual describes in detail the institutional and implementation arrangements for the project, including the roles and responsibilities of all key stakeholders. It defines the procedures for accessing project funds and the criteria for the selection and approval of work plans. The manual spells out the contractual arrangements between the CNLS and the implementing agencies and includes standard contracts and Memorandum of Understanding to be utilized. The manual defines procurement procedures and threshold levels and financial management arrangements, including reporting requirements at all levels. D. Project Rationale 1. Project alternatives considered and reasons for rejection: Choice of instrument The Second Phase of the Multi-Country HIV/AIDS Program (MAP), which is a horizontal APL, offers Rwanda the exceptional opportunity to have access to grant funds in the immediate future. It also allows for sustained and phased support in the future within the MAP framework. This is clearly an optimal solution and no other lending instruments could offer better terms. Project alternatives The following alternatives were considered and rejected: * Health vs Multi-sectoral approach: The team considered preparing an operation that focused on the health aspects of the HIV/AIDS epidemic and rejected this option. The creation of the National HIV/AIDS Commission (CNLS) represents an important milestone in mounting a concerted national response and signals the government's commitment to a multi-sectoral approach. While the Ministry of Health is expected to continue playing a pivotal role there is widespread recognition that bringing about behavioral change will require the involvement of all stakeholders. Hence, the project is institutionally attached to the CNLS that is in the best position to coordinate and guide this -23 - multi-sectoral approach. * HI VIAIDS components in other IDA operations or self standing operation: The option of expanding activities undertaken in the framework of other IDA-funded ongoing community development projects to include HIV/AIDS interventions was also rejected as it would have diluted the importance attached to HJV/AIDS. Likewise, it would not have allowed for the need to reinforce the capacity of line ministries, including the Ministry of Health, to combat HIV/AIDS. 2. Major related projects financed by the Bank and/or other development agencies (completed, ongoing and planned). - . - -. ~~~~~~~~~~~~Latesit Supervision Sector Issue Project f (PSR) Ratings ._______________________________ ', ,___... ___... ___ _... _ -f(Ba nn an ced projects only). Implementation Development Bank-financed Progress (IP) Objective (DO) Agriculture & Rural Market S S Development Community Reintegration S HS (CRDP) Competitiveness & Enterprise S S Development Demobilization & Reintegration Human Resources S S Development Rural Water Supply & S S Sanitation Project Regional Trade Fac. Project S S Rural Sector Support Project S S Other development agencies Belgium Cooperation Health district support. Luxembourg Cooperation Laboratory support; ARV support under discussion. USAID VCT/STIs integrated activities in five provinces; NGO support for community-based programs; support for behavioral surveillance surveys. Centers for Disease Control (CDC) Technical assistance to TRAC; support for strengthening surveillance and VCT/STI activities. KFW Social marketing of condoms. GTZ HIVIAIDS and family planning activities in 2 districts. DED Technical assistance in HIV/AIDS in one health - 24 - district. DFID Technical and financial support to the Ministry of Education; support to NGOs and associations for regional HIV/AIDS activities through Action Aid. Swiss cooperation Support for youth related activities UNICEF Support for PMTCT program, IEC activities for youth,-and support for orphans. UNDP Support for strengthening CNLS; financial support for activities of Ministry of Defense, and activities. to mitigate impact of epidemic. UNFPA Technical and financial support for reproductive health, HIV, STI program for youth; support for community based condom distribution schemes. UNAIDS Support for HIV/AIDS activities with military and PACFA (First Lady's Office). WHO Technical assistance for HIV surveillance, VCT, and PMTCT activities. UNESCO Support for awareness raising activities in schools. IP/DO Ratings: HS (Highly Satisfactory), S (satisfactory), U (Unsatisfactory), HU (Highly Unsatisfactory) 3. Lessons learned and reflected in the project design: Rwanda has incorporated into the proposed project design many of the lessons derived from the global response to AIDS, as well as from other MAP operations and national projects, namely the need for: * Demonstrating staunch commitment at the highest level of the government and civil society, with the President of the Republic providing strong leadership. * Building partnerships with the private sector and civil society, including non-governmental organizations and community associations which have proven to be essential players in the fight against HILV/AIDS. * Adopting a decentralized and participatory approach that mobilizes a broad spectrum of society, including communities, local leaders, and people living with HII/AIDS. * Adopting multi-sectoral responses and involving all public sector institutions (e.g. defense, education, youth, local government). * Promoting a comprehensive approach that includes the full range of interventions (e.g. behavior change, STI control, condom distribution, community based care and support, and advocacy) through the adoption of a unique integrated VCT model that is being replicated nationally. - 25 - The experience from the first group of MAP countries has brought out a number of other key lessons with regard to the start up of several operations which Rwanda has taken into account: (a) adopting a sequenced and phased approach that takes into account capacities of different actors; (b) designating a core group of dedicated staff in the secretariats of the national coordinating EIV/AID bodies and in participating line ministries; (c) carrying out institutional assessments early on with a particular focus on the roles and responsibilities of key actors; (d) preparing solid manuals (i.e. operational, administrative and financial) which are critical to effective implementation; and (e) developing an effective communications (IEC/BCC) strategy that is essential to the success of MAP operations. Other important lessons have been gleaned from the recently completed Population and AIDS Control Project. First, the relatively small but successful experience with a social fund managed by the PLNS for channeling funds for RIV/AIDS activities to community groups has demonstrated the potentially important role which community associations can play and the types of modalities which can be used for channeling funds to these groups. It has also highlighted the need to build capacities amongst these organizations in order to expand and scale up promising approaches. Second, another key lesson relates to the need to address human resources needs more comprehensively in order to ensure a sustained development of the health system in Rwanda. The massive brain drain experienced following the tragic events of the 1990s, combined with the AIDS epidemic, have exacerbated Rwanda's human resources problems. Particular attention needs to be given to rebuilding capacities and developing incentives for staff to be deployed to under-served areas. Third, there is a need to build complementarities between the govemment's reproductive health (RH) and the HIV/AIDS program to avoid undermining RH needs at the cost of scaling up HIV/AIDS efforts. The inter-agency thematic group is already promoting an integrated approach to reproductive health and HIV/AIDS activities at various levels of the health system. It will be important that efforts to scale up HIV/AIDS care and treatment through the MAP maintain the holistic approach envisioned in the country's reproductive health strategy. Of particular importance will be combining VCT/PMTCT with other family health services that will have several positive effects, including avoiding stigma for services that are exclusively AIDS-oriented and addressing the range of maternal and child health needs. Other potential areas for collaboration between the RH and RIV/AIDS programs include: (a) improving targeting and delivery of behavior change communication messages to reap synergies; (b) supporting NGOs and associations which are active in both areas; and (c) exploring ways of tapping the network of health sector community workers (animateurs de sante) so that they may play a pivotal role in disseminating complementary and mutally reinforcing messages. Lessons from other Bank-financed projects in Rwanda, particularly in the post-genocide environment, has highlighted important lessons which the preparation team has strived to address: (i) giving particular attention to financial management arrangements; (ii) providing staff training in Bank procedures from the outset of project preparation; (iii) adopting participatory approaches that are broadly inclusive and building partnerships between local groups and communal authorities. - 26 - 4. Indications of recipient commitment and ownership The Government of Rwanda is strongly committed to the fight against HIV/AIDS, having mobilized high-level support from both the political and religious establishment. Tackling the HIV/AIDS epidemic is seen as a major national priority. Both the President and First Lady are highly committed to this program. The establishment of the National HIV/AL)S Commission in the office of the President has enhanced the visibility of the program. The leadership of the National Commission by an Episcopalian bishop is illustrative of the multi-sectoral nature of this program and has sent a strong signal to all groups that they have a role to play in the struggle against this epidemic. The recently adopted 2002-2006 multi-sectoral lIV/AIDS Strategic Plan corresponds to recognized best practices internationally. An extensive, bottom up, consultation process went into the preparation of this plan, which augurs well for ownership and ultimate success. Implementation of the program is also expected to be broad-based. A number of sectoral programs are well underway, as mentioned above. Rwanda's youth have been proactive, having organized themselves into a National Youth Council to spearhead their own program. The strong commitment and involvement of youths is essential for the success of the national program. The First Lady's office is promoting a family care project for individuals and families infected and affected by HIV/AIDS. Rwanda's rapid approval of the Global Fund proposal confirms the confidence of the development community in the country's leadership and their commitment to the struggle against HIV/AIDS. Finally, while Rwanda is joining the MAP somewhat later than its neighbors, it has the potential to play a critical regional role in the fight against the epidemic and is committed to assuming this role through the regional HIV/AIDS coordinating body (GLIA) that is based in Kigali. In light of the need to ensure effective containment of this infectious disease within the Great Lakes area, and given the high externalities associated with this illness, it is expected that the Rwanda MAP will channel grant funding to GLIA to coordinate and oversee regional activities. 5. Value added of Bank support in this project: The Bank has provided leadership, in the donor community by assisting Rwanda rebuild its economy and society following the 1994 genocide. The modest progress attained in recent years is not sustainable, however, if strong efforts are not made to mount an effective national response. Rwanda's participation in MAP IH will bring the financial support needed to broaden multi-sectoral activities and to scale up promising approaches. It will complement activities supported by other donors and by the Global Fund. The country will become part of the MAP network of countries which exchange experiences on a regular basis and have access to cutting edge knowledge. Rwanda's participation in MAP II signals the Bank's long-term commitment to providing financial and technical support to tackle the epidemic. E. Summary Project Analysis (Detailed assessments are in the project file, see Annex 8) 1. Economic (see Annex 4): O Cost benefit NPV=US$ million; ERR = % (see Annex 4) O Cost effectiveness * Other (specify) As the project is part of the Multi-Country HIV/AJDS Program for the Africa Region (Report No. 20727 AFR) no specific economic analysis was carried out. The economic analysis contained in the PAD for the MAP I operation contains the overall economic justification and underpinnings for the -27 - Rwanda MAP. This analysis included an overall assessment of the impact of HIV/AIDS on the economy as well as a cost-benefit analysis of HIV/AIDS interventions. The main findings of the assessment can be summarized as follows: * HIV/AJDS has a negative effect on productivity levels, domestic savings and overall economic growth. * HILV/AIDS increases health costs and runs the risks of crowding out other key public health programs, such as immunization, maternal and child health, malaria and parasitic diseases. * Care and treatment of AIDS patients imposes high costs on families and reduces their earning capacity. * Family coping strategies may result in children abandoning school or the family cuting other health or social expenditures to unacceptable levels. 2. Financial (see Annex 4 and Annex 5): NPV=US$ million; FRR = % (see Annex 4) N.A. Fiscal Impact: The fiscal impact of the project is expected to be negligible with the exception of the ARV therapy interventions which will generate considerable recurrent costs. These additional costs will need to be assumed by the government or by others to allow individuals to continue their treatment for the duration of their lifetimes. This analysis is currently underway as part of the ARV assessment described below. A fuller analysis of the recurrent cost implications is being built into the project, to the extent that participating organizations will be requested to systematically collect this type of data. The HIV/AIDS thematic group in Rwanda has been concerned with getting a better handle on the overall level of spending and commitments for HIV/AIDS and has commissioned a consultant to assemble this information which is included in Annex 15. The MAP team will continue to work closely with other development partners to ensure close coordination of these activities and to monitor costs. 3. Technical: ARV service provision In September, 2002, a multi-disciplinary team from CDC/USDHHS (Center for Disease Control and Prevention, US Department of Health and Human Services) was commissioned by the World Bank to conduct an in-depth analysis of the current status of antiretroviral (ARV) therapy and HIV care provision in Rwanda under a PHRD grant awarded by the Japanese government. The recommendations stemming from this analysis will assist in the design of a comprehensive care and treatment component, including the provision of ARV therapy for the MAP. The CDC team in collaboration with the government and other partners has proposed a number of service delivery models. The goal has been to complement on-going activities led by other donors, and be applicable to efforts to rapidly scale up the ARV program. A joint team composed of members of the Treatment and Research AIDS Center (TRAC) of the Rwandan Ministry of Health and the Centers for Disease Control and Prevention (CDC) conducted the situation analysis in November 2002. The team visited sites representing a broad spectrum of health care facilities in Rwanda and providing various levels of health care ( i.e. reference hospitals, district hospitals, and health centers). The sites visited also reflected a range of levels of resources (i.e. some solely government supported facilities, some run by the government in collaboration with religious missions, and others belonging to the private sector). In total, the team toured eleven sites: five of the six - 28 - health care facilities currently providing ARV therapy in Rwanda (three reference centers, a rural health center and a private employee clinic); three of the four sites planning to provide ARVs drugs in the next year; and three naive sites which had some HIV-related services but no plans to provide ARVs in the near future. At each site, the team toured the clinical facility and interviewed staff about the population they served and the range of HIV-related services they provided. The team also met with key stakeholders interested in scaling up provision of ARV therapy. Current status & key issues Approximately 900 HIV positive persons currently receive ARV therapy in Rwanda. As is true of most developing nations, the cost of the medications severely limits the number of people able to benefit from ARV therapy. Bearing the cost of these drugs greatly impacts the ability of individuals to adhere to therapy. Many clinicians interviewed reported that their patients often forego the reconmmended laboratory tests used to monitor therapeutic response and/or toxicities in lieu of affording another month of ARV therapy. A second challenge faced by Rwanda is the centralization of laboratory support and medical care in Kigali. At present, only the central TRAC laboratory facility can perform CD4 counts and viral load measurements. Although the small geographic size of the country and a system of well-maintained main roads make specimen transport feasible, this service is not yet available. Instead, many patients residing outside of Kigali must transport themselves to the capital to have their blood drawn. HIV care services, particularly access to ARVs, are also concentrated in Kigali. Less than 100 of the 900 patients on ARV therapy receive treatment in health care facilities located outside of the capital city. Of the four designated reference centers, three are located in Kigali. The fourth center, the University Hospital of Butare, houses the only existing medical and public health schools in the country. In Butare, only 54 of the 5,000 patients attending the hospital whom are known to be HIV infected receive ARV therapy. Priorities & strategies Based on findings from the site visits and discussions with various stakeholders and implementing agencies, the CDC team outlined a series of recommendations for the development of the ARV pilot program. The CDC report (January 2003) forms the basis for the design of the diagnosis, care and treatment of B[V/AIDS patients activities. Bearing in mind the need for future replication and expansion, the CDC assessment proposed both site-specific capacity for providing ARV therapy as well as central level infrastructure. As noted in the report, at the site level, realistic expansion of access to ARVs will require providing medications at low or no cost to patients and similar efforts to reduce the cost of recommended laboratory tests. The CDC team recommended a multi-site pilot program that could address implementation issues at several health care facility levels. Given the limited human resources at TRAC to coordinate an ARV pilot program, the team suggests a phased-in approach to implementing a multi-site pilot program. This would allow rapid deployment of MAP resources among sites with immediate readiness while supporting on-going development of central support systems (e.g. multiple reference centers, extended CD4 capacity, procurement system for laboratory supplies). Another site-selection recommendation made by the team is to develop the University Hospital of Butare into a reference center for the South-west region of Rwanda. While the development of Butare into an HIV care and treatment reference center would require significant investment of resources and time, a number of opportunities for national capacity building exist. First, the School of Public Health has expressed interest in becoming a training center for the ARV reference center. In addition, the facility has a strong laboratory department with sufficient staffing and facilities to support ARV-related services. Finally, the University of Butare Hospital benefits from a motivated staff interested in participating in a consortium of ARV providers. - 29 - In addition to recommendations noted above with respect to specific pilot sites, the team also identified a number of areas where World Bank funds would provide critical support for central system development. Many of the central system support activities will require MAP coordination with other major donors and implementing agencies to avoid duplication of effort and to stagger activities which depend heavily on TRAC human and material resources. System development would include: * Convening multi-disciplinary teams of experts to review national HIV care guidelines and discuss national HIV care policies * Expanding laboratory capacity for processing CD4 count * Assuring routine updates of the CAMERWA formulary by a panel of experts * Extending CAMERWA's role of drug procurement to all laboratory and clinical supplies * Creating a specimen transport system between health care and laboratory facilities * Acquiring facilities and staff to provide training and quality assurance for ARV programs * Expanding TRAC capacity to coordinate and supervise emerging and on-going ARV programs The program models developed by the CDC team incorporate many of the program elements described above. Each model focuses on building capacity for providing ARV therapy at a different combination of health care levels (i.e. reference centers, district hospitals, health centers, etc.). These models all emphasize the development of strong linkages between health care facilities, as well as between the health care facilities and their respective district health teams. These types of relationships are critical to supporting integrated IRV care services. The pilot ARV program will extend and prepare the groundwork for future activities supported by Global Funds I (awarded) and an eventual Global Fund II award. The MAP ARV sites would capitalize on opportunities to collaborate with other implementing and donor agencies to build capacity and test models in rural and urban settings outside of Kigali. During negotiations the Bank team discussed with the Rwandan delegation the size, scopeand scale of the HIV/AIDS Care and Treatment Component, including the financing of ARV therapy. The goal of this initiative is to establish 12 learning sites outside of Kigali for the provision of a comprehensive package of services, including treatment of sexually transmitted infections, opportunistic infections, and ARV therapy. This will be done through a decentralized approach using public-private partnerships at the hospital level. The initiative will piggyback on to the integrated VCT/PMTCT sites, being supported under the Global Fund I. The provinces which have been tentatively selected are Butare in the South, Umutara in North-East, and Cyangugu in the South-West. In these provinces the goal is to strengthen the provincial hospitals to allow for the treatment of up to 300 patients per site and to build up the district hospitals to enable them to treat on average about 150 patients. In total, up to 2,350 patients may be placed under treatment. This initiative will improve geographical coverage by complementing support provided by other development partners and provide the elements for an eventual scale up. The Bank team has agreed with the Rwandan delegation on the need to submit a comprehensive action plan, satisfactory to IDA, prior to initiating these activities. The plan would include: (a) criteria for site selection; (b) choice of sites; including a combination of public and NGO-administered facilities; (c) sequencing and phasing of investments; (d) plans for conducting staff training, strengthening laboratory capacity, building the referral system, monitoring patients and conducting operational research; and (e) socio-economic criteria to be used for patient selection and a pro-poor subsidy scheme for the provision of these services. This action plan would also include the government's proposal for strengthening the Research and Treatment Center on AIDS (TRAC) of the Ministry of Health with key personnel (i.e. director, care coordinator, and a VCT coordinator). - 30 - 4. Institutional: An institutional assessment of the CNLS and its key stakeholders was carried out in August 2002 under a Japanese-funded PHRD grant. Capacity was assessed in terms of leadership, resources and work practices. The assessment found that the Rwandan national program has many strengths, including strong leadership at the highest political levels and a dedicated group of volunteer commissioners at the district level who have been proactive in mobilizing broad based support. These leaders have mounted a strong strategic planning process at the national, provincial and sectoral levels and in a variety of other areas. The planning process appears to have followed a systematic approach, indicating that communication and coordination has been effective and demonstrating strong leadership. The capacity assessment mission also found a number of capacity gaps which need to be addressed. These can be summarized as follows: * Appraising, screening & approving sub-projects: The assessment concluded that the CNLS system at all levels needs to be considerably strengthened to manage the level of projected resources it will be receiving in the near future. To this end, it will be important to put in place structures, procedures, eligibility criteria and personnel for screening, approval and monitoring of sub-projects. This will be one of the key areas of capacity building during the first year. * Determining administrative & staffing arrangements: The assessment also highlighted the need to determinie administative and staffing arrangements at different levels of the CNLS system and for recruiting and training the core personnel. This process is now well underway with terms of reference elaborated for all key positions. * Carrying out workload analyses: In order to better determine capacity needs all stakeholders need to incorporate into their work plans a detailed accounting of expected workloads. The capacity asssessment found a virtual absence of such workload analysis which would aid in determining staffing and training needs. The capacity assessment took a rapid look at the CNLS structures at the provincial, district and local levels and found a need to clarify the roles and responsibilities of these structures and to strengthen their capacity. To this end, it was suggested that the activities to be carried out at these levels need to be identified, so that staffing, training and technical assistance needs could be determined. Technical assistance is being provided under a PHRD grant to assist these CNLS structures to identify their capacity building needs and to prepare their work plans for 2003, so that once the IDA grant becomes effective the activities can be initiated quickly. 4.1 Executing agencies: The assessment mentioned above also considered the capacity of public sector.organizations to be involved in the implementation of the project. The assessment on a small sample of public sector organizations found different cultures and procedures and levels of capacity, suggesting a need for a phased approach, whereby for some institutions the focus in the first year is on building capacity and subsequently on carrying out sector-specific responses. 4.2 Project management: The government of Rwanda has confirmed to the Bank its intention to establish a Project Management Unit (PMU) within the Executive Secretariat of the CNLS. The PMU is expected to play a - 31 - pivotal role in financial management, procurement, and progress reporting. During the course of the September 2002 pre-appraisal mission the Bank team agreed with Rwandan authorities on a timetable for establishing and staffing the Project Management Unit. The Government carried out a competitive process for recruiting the core team for the PMU, including a Project Manager, Financial Management Specialist, and a Procurement Specialist. The selection process was carried out in a transparent manner and is fully documented in the selection panel's report which was forwarded to the Bank on February 13, 2003. The outcome was that the Project Manager and Financial Management Specialist were selected but that a suitable Procurement Specialist was not identified. The government has re-advertised the Procurement Specialist position and expects to complete the selection process by March 31, 2003, along with the selection of a procurement consultant who will assist in training staff. During negotiations the Bank team reviewed with the Rwandan delegation the staffing plan for the Project Management Unit and agreed upon the selection of the remaining staff by grant effectiveness. This would include: three project officers (i.e. Public Sector, Private Sector, Monitoring and Coordination). 4.3 Procurement issues: The last Country Procurement Assessment Review (CPAR) carried out for Rwanda is no longer relevant as the procurement system has been changed. A new CPAR is planned for FY04. A reform of Rwanda's procurement system is currently underway. This reform is expected to result in the establishment of new procurement laws and regulations, including standard bidding documents inspired by the Bank's standard models. Experience to date has found that procurement procedures in Rwanda do not conflict with Bank guidelines. Furthermore, Rwandan procurement practices allow IDA procedures to take precedence over any contrary provisions in the national regulations. The National Tender Board has the overall responsibility for procurement of contracts over RwF3.0 million to be awarded by public entities. The formalization of NTB's status by a legal document (law or decree) has been pending for more than three years. While this issue needs to be resolved in the near future, it has not hindered the handling of procurement matters under IDA-funded projects in Rwanda. To date, the NTB has established a set of guidelines that are being used effectively by public agencies in Rwanda. The NTB is staffed with relatively young staff, who are well educated but lack significant work experience. Staff dealing with IDA projects have attended procurement-training organized or supported by the Bank. To further strengthen knowledge of Bank procurement procedures and guidelines, the NTB needs to: (i) strengthen procurement planning in public sector agencies; (ii) improve procurement filing and documentation systems in the public sector; (iii) reduce delays in the procurement process; and (iv) ensure consistency and transparency in procurement decisions. The project will provide support aimed to address these weaknesses and to strengthen overall procurement capacities of institutions to benefit from this operation. To this end, the project would finance the following activities: (a) training of NTB staff so that they may serve as trainers; (b) recruitment of a short-term consultant to assist different institutions to establish adequate procurement plans and develop mechanisms for monitoring the implementation of procurement activities; and (c) hiring of a short-term consultant to design and set up an adequate procurement filing system. The government has selected CAMERWA to function as the procurement agent for drugs, including anti-retroviral drugs, and medical supplies to be procured under the HIV/AlDS Multi-Sector Project. CAMERWA was transformed from a public sector entity into a non-profit organization in December 1998 with the assistance of the IDA-funded Health and Population Project. It has the overall responsibility for the procurement of low cost, high quality generic drugs and medical supplies for the public sector in Rwanda. To date, this relatively young institution has proven very effective in fulfilling its mandate. The assessment carried out by the Bank mission concluded that CAMERWA is well placed to handle all procurement related to drugs and medical supplies under this operation. -32 - The Project Management Unit, which will handle procurement under this operation, is being established. As indicated above, the Procurement Specialist has not been selected because a fully qualified candidate was not identified. The Government has been duly diligent in seeking to fill this post, and has already re-advertised this position. In the meantime, the CNLS is using its own Procurement Specialist who has been involved in preparing the procurement section of the operational manual and is preparing the draft procurement plan. Based on the procurement assessment carried out during the pre-appraisal mission, the overall risk assessment is high, particularly as the Project Management Unit remains to be fully established. 4.4 Financial management issues: The key financial management risks arising from the Country Portfolio Performance Review (CPPR) completed in July 2002 and the Financial Acountability Review carried out in September 2002 which may impede implementation include: (i) delays in providing counterpart funds; (ii) weak institutional and human resources capacities; (iii) late submission of audit reports; and (iv) weaknesses in budgetary processes, public sector accounting and reporting and internal auditing. To address these financial management risks the government has agreed to implement the following mitigation measures: * Put in place adequate financial management arrangements, including efficient flow of fund mechanisms, establishing two Special Accounts, organizing for external audits, elaborating a Manual of Administrative, Financial and Accounting Procedures and recruiting qualified financial management staff. * Make an initial advance deposit into the local account as part of the counterpart funds. * Prepare a project operational plan for the first year and approve the work plans and budgets of three line ministries and three CPLS for the first year. * Provide periodic training during the life of the project on Bank procedures and guidelines (e.g. financial management, disbursement, project planning, budgeting and monitoring & evaluation). 5. Environmental: Environmental Category: B (Partial Assessment) 5.1 Summnarize the steps undertaken for environmental assessment and EMP preparation (including consultation and disclosure) and the significant issues and their treatment emerging from this analysis. The project is not expected to have any major adverse environmental effects. The handling and disposal of IIV/AIDS infected materials is the most significant environmental issue. These risks potentially affect the following stakeholders: (i) health and paramedical personnel who run the risk of exposure (e.g. blood contamination; infections; intoxications); (ii) support staff who handle waste disposal; many of these individuals who are responsible for collecting and disposing of waste management work in sub-optimal hygienic conditions which does not protect them adequately from the risks of exposure to contaminated products; (iii) patients who also run the risk of exposure due to the variable quality of waste management practices in hospitals and health facilities; and (iv) households whose livelihood depends on triage of waste. Given pervasive poverty in Rwanda, poor households are particularly vulnerable to exposure given their relatively low education levels and vulnerability. To address potential risks and identify remedial actions a waste management assessment has been carried out. The August 2002 assessment raised concerns with respect to: (i) air pollution resulting from burning of waste products; (ii) water pollution stemming from inappropriate disposal of wastes; and (iii) risks of exposure to contaminated products for various stakeholders (i.e. medical, support, patients, poor households, general population). As described in the report, the handling and disposal of waste management products in health facilities suffers from a number of weaknesses: lack of equipment and - 33 - supplies; personnel shortages; poor knowledge of risks and mitigation measures; lack of procedures for waste management; and absence of private sector waste management firms. The government's Waste Management Plan proposes to address the following objectives: * Improving legal, institutional and technical framework by elaborating appropriate legislation and developing protocols and guidelines. * Strengthening waste management practices in hospitals and health facilities by: (i) introducing regulatory measures; (ii) allocating budgetary resources for financing these activities; (iii) introducing a triage system whereby hazardous materials are separated for incineration; (iv) promoting use of recyclable materials; and (v) developing appropriate waste management disposal systems for the different types of health infrastructure. * Training hospital personnel and waste management operators. * Increasing awareness amongst the population of the risks associated with these hazardous materials and of the need to adopt hygienic practices at the household level. * Fostering private sector participation in the management of waste products by strengthening private sector capacities and promoting public/private partnerships. * Providing appropriate equipment (e.g. incinerators, hazardous waste trashcans); and materials to health facilities to assure that wastes are disposed in a safe manner. * Disseminating, validating and carrying out the national waste management plan. 5.2 What are the main features of the EMP and are they adequate? A Waste Management Plan was prepared and sent to the Info Shop. 5.3 For Category A and B projects, timeline and status of EA: Date of receipt of final draft: October 2002 5.4 How have stakeholders been consulted at the stage of (a) environmental screening and (b) draft EA report on the environmental impacts and proposed environment management plan? Describe mechanisms of consultation that were used and which groups were consulted? The Waste Management Plan was disseminated and discussed with key stakeholders. 5.5 What mechanisms have been established to monitor and evaluate the impact of the project on the environment? Do the indicators reflect the objectives and results of the EMP? Government is considering which indicator(s) would be most appropriate for monitoring the impact of the project on the environment. 6. Social: 6.1 Summarize key social issues relevant to the project objectives, and specify the project's social development outcomes. The project will have a positive social impact by raising awareness of HIV/AIDS prevention and by encouraging safe sex, particularly among the most vulnerable groups (i.e. youth, women).. Community and civil society initiatives will have beneficial effects in assisting and empowering individuals, communities and institutions to deal more effectively with the disease burden. 6.2 Participatory Approach: How are key stakeholders participating in the project? Stakeholders have been extensively consulted during the preparation of the project. Consultations took place in each province. Meetings were held with representatives of public agencies and private enterprises, local groups, women's associations, youth clubs. This consultation process is - 34 - described in detail in the government's project proposal. The draft operational manual was discussed with representatives of civil society to incorporate their views. Participatory approaches will be used during the life of the project. 6.3 How does the project involve consultations or collaboration with NGOs or other civil society organizations? NGOs and associations will be one of the key beneficiaries of this project with substantial support under component #3. These organizations will assist communities to facilitate the design, implementation and monitoring of community sub-projects. Simple contractual agreements will be used for the design of sub-projects. Organizations will be asked to use a set of simple indicators for monitoring results. 6.4 What institutional arrangements have been provided to ensure the project achieves its social development outcomes? The participatory approach used during the preparation of this project will be continued during the implementation phase. The CNLS proposes to carry out beneficiary assessments to ascertain the views and perceptions of key stakeholders throughout the life of the project. Furthermore, the multi-sectoral and multi-disciplinary nature of the CNLS management structures at the central and local levels will facilitate in monitoring the expected social development outcomes of the project. 6.5 How will the project monitor performance in terms of social development outcomes? Indicators of beneficiary satisfaction will be included in the monitoring and evaluation system. In addition to qualitative information from the beneficiary assessments; information will be collected during exit interviews at health facilities to determine the degree of satisfaction with the quality of care received. 7. Safeguard Policies: 7.1 Are any of the folloAving safeguard policies triggered by the proect? . : -- - - Policy . r- P6-1y - -Triggered - Environmental Assessment (OP 4.01, BP 4.01, GP 4.01) * Yes (No Natural Habitats (OP 4.04, BP 4.04, GP 4.04) (9 Yes 0 No Forestry (OP 4.36, GP 4.36) (9 Yes * No Pest Management (OP 4.09) (9 Yes * No Cultural Property (OPN 11.03) (9 Yes * No Indigenous Peoples (OD 4.20) ( Yes * No Involuntary Resettlement (OP/BP 4.12) ( Yes * No Safety of Dams (OP 4.37, BP 4.37) ( Yes * No Projects in International Waters (OP 7.50, BP 7.50, GP 7.50) ( Yes * No Projects in Disputed Areas (OP 7.60, BP 7.60, GP 7.60)* C)Yes * No 7.2 Describe provisions made by the project to ensure compliance with applicable safeguard policies. See section #5 above. - 35 - F. Sustainability and Risks 1. Sustainability: The project is likely to be sustained to the extent that there is strong ownership, participation and commitment. Likewise, a major effort is being made to strengthen implementation capacities at all levels; and the government plans to decentralize the program to regional and local authorities. Capacity building interventions are built into all components, with a focus on designing solid action plans, incorporating performance measures to monitor results, and developing mechanisms for supervision and follow-up. While the decentralization process is somewhat slow, these efforts will bear fruit as local authorities are empowered to assume greater responsibility in the fight against HIV/AIDS and are made accountable for the results attained. Working towards a common goal should also strengthen the broader reconciliation effort in Rwanda and ultimately enhance sustainability. Against these sustainability-enhancing measures there are lingering concerns with the financial sustainability of the national program, particularly in light of growing pressures to increase access to ARV therapy. - 36 - 2. Critical Risks (reflecting the failure of critical assumptions found in the fourth column of Annex 1): Rlisk Risk Rating - ARsk Mitigation Meiasure From Outputs to Objective Government commitment not sustained M While political commritment is expected to be maintained there are concerns about the government's ability to provide adequate human and financial resources to facilitate effective implementation. A co-financing strategy was agreed upon during negotiations CNLS and State Ministry in charge of M The operational manual spells out in detail the HIV/AIDS have conflicting roles and responsibilities of the CNLS and of responsibilities with regard to project the State Minister responsible for HIV/AIDS and other infectious diseases Preventive measures do not translate into S Expand access to an integrated package of behavior change preventive and support & care measures which are expected to improve the effectiveness of preventive measures Health system remains weak and unable S Provide financial support to continue to provide a range of quality strengthening service delivery system, interventions including the supply chain management for the delivery of HIV/AIDS commodities Health personnel retain negative attitudes S Expand staff training in both technical areas towards PLWHA and in behavioral change in order to better cope with need of infected individuals From Components to Outputs Slow start up owing to insufficient S Carry out project launching activities to capacity and inexperience of line motivate participation and provide training and ministries, NGOs, and associations technical support to assist in design and execution of work plans Program management is less effective S Build into the project an assessment of program than expected management effectiveness in order to monitor progress and make changes, as deemed necessary Overall Risk Rating Risk Rating - H (High Risk), S (Substantial Risk), M (Modest Risk), N(Negligible or Low Risk) - 37 - 3. Possible Controversial Aspects: A number of possible controversial aspects surround the implementation of the Rwanda MAP. First, sexual behavior remains a fairly taboo subject in Rwanda, which is a predominantly traditional society. Religious missions continue to play a major role in the country and in the health sector, and are generally not comfortable with promoting condom use among their constituency. This controversial aspect would be handled through appropriately targeted messages and behavioral change communications, which disseminate messages through peer educators. Second, the eventual introduction of an ARV pilot component under the project raises a host of possible controversial aspects. These include: (i) pressures to select participants, as the number of people requiring treatment will exceed financial and institutional capacities; (ii) risk of leaving behind the most needy who have limited negotiating skills and low levels of education; and (iii) concerns over financial sustainability, particularly in light of the large pool of infected persons and the high cost of drugs for this chronic illness. These controversial aspects would be managed through a carefully designed and monitored pilot with strong technical support from specialized intemational agencies. Third, there does not appear to be an explicit policy on how to target special groups, such as demobilized ex-combatants, retumees and prisoners. This aspect would be addressed by encouraging NGOs to target these groups as they have a comparative advantage in working with these groups. G. Main Grant Conditions 1. Effectiveness Conditions The Government has: o Established the Project Management Unit in a form and with functions, resources and staffing, satisfactory to IDA, and appointed thereto a Project Manager, Procurementt6pecialist, Financial Management Specialist and three Project Officers. o Adopted a project implementation plan and a procurement plan for the 1st year, acceptable to IDA. O Opened one Project Account for reception of counterpart funds, and made the initial advance deposit in an amount equivalent to US$75,000. o Appointed independent external auditors, satisfactory to IDA. 2. Other [classify according to covenant types used in the Legal Agreements.] N/A H. Readiness for Implementation D 1. a) The engineering design documents for the first year's activities are complete and ready for the start of project implementation. S 1. b) Not applicable. D 2. The procurement documents for the first year's activities are complete and ready for the start of project implementation. z 3. The Project Implementation Plan has been appraised and found to be realistic and of satisfactory quality. C 4. The following items are lacking and are discussed under loan conditions (Section G): During negotiations it was agreed that by March 31, 2003, the government will update the project implementation plan for the first year of the project. - 38 - 1. Compliance with Bank Policies 3 1. This project complies with all applicable Bank policies. LII 2. The following exceptions to Bank policies are recommended for approval. The project complies with all other applicable Bank policies. Mfaf48chneidrmaEVnxul(b Team eader Sector Manager Country Director 39 - Annex 1: Project Design Summary REPUBLIC OF RWANDA: Multi-Sectoral HIV/AIDS Project Key Performance Data Collection Strategy- - 'Hlerarvhyo b ttves < -' '-.'indicators , - Critical Assumptions Sector-related CAS Goal: Sector Indicators: Sector/ country reports: (from Goal to Bank Mission) Reduce poverty. The proportion of people Annual UNDP Development Sustained Govermnent below the absolute poverty Report. commitment. line will either stabilize or reduce by the end of the World Bank Reports Ensure access to basic health project. Suciessful developnent and and social services by the Poverty and Sector Reports. implementation of public poor. sector, civil society, and private sector strategies. Increase emnployment and Life expectancy will either Increasing political and social income-generating activities stabilize or begin to stability. for the poor. increase by the end of the project. Program Purpose: End-of-Program Indicators: Program reports: (from Purpose to Goal) To scale-up the national Decline or stabilization in MOHTfRAC and CNLS Increasing capacity at all multisectoral response to HIV/AIDS prevalence Annual Reports and Project levels HIV/AIDS in Rwanda, with reported in antenatal settings Completion Report particular emphasis on vulnerable groups. Decline in reported STIs Project Development Outcome / Impact Project reports: (from Objective to Purpose) Objective: Indicators: Behavior change: Project Reports: Prevention activities Increase in percent of BSS translate to behavior 1) Scale up, expand and never-married youth (15-19 change. strengthen prevention years) reporting condom activities in effort to reduce use in most recent act of the risk of HIV premarital sex with a transniission non-commercial partner. Females: 2000 baseline of 11.3%; 2008 target of 25%; Males: 2000 baseline of 19.6%; 2008 target of 40%;. Age at first sex among young people (15-19 years) BSS Females: 2000 baseline of -40 - 14 years at first sex; 2008 target of 15 years Males: 2000 baseline of 13 years at first sex; 2008 target of 14 years Increase in percent of men DHS (15-49 years) who report condom use the last time they had sex with an unmarried, non-cohabitating partner in the last twelve months 2000 Baseline of 51%. 2008 Target: 70% TRAC *Increase in percent of clients who bring partners for VCT services. Pregnant women: 2002 baseline of 24%; 2008 target of 44%; Non-ANC VCT clients: 2002 baseline unknown; target of 30%; TB patients: 2002 baseline: unknown, 2008 target of 30%. 2) Strengthen capacity to Care and Support Service delivery surveys Strong public health system is provide care, treatment, and *Increase in percent of (IP6/IP7) able to provide a range of support to those infected or clients who are quality interventions. affected by the HIV/AIDS appropriately diagnosed epidermic. and treated according to National Guidelines. 01: Baseline of 0%; 2008 Target of 60%; Strong public-private STI: Baseline of 66.5%; partnership in the delivery of 2008 Target of 75%. health and social services Percent smear-positive TB cases who complete DOTS protocol. PNILT & Health Centers Baseline of 75%; 2008 Target of 85%. -41 - Increase of 20% in the Ministry of Health number of households involved in "mutuelle" schemes supported by the project by 2008. Capacity at community-level to Discrimination & Stizma implement workplans. Decrease of 20% in the proportion of PLWHA Beneficiary Assessment reporting stigma and discrimination by 2008. Child Welfare Reduction of 20 percent in differential school DHS attendance ratio between Availability of local orphans aged 10-14 (who NGOs/CBOs and have lost both parents) and associations with sufficient non-orphans by 2008. capacity. 2000 baseline for females of 0.86; 2000 baseline for males of. 0.76 -42 - ,.7:-Key PeiFormance '| ;atiC~olection.Straegy -- -- !-;Hierarchyof,Objectives- .e- lndicators - s-ui0j '.o- ;Critica * p n Output from each Output Indicators: Project reports: (from Outputs to Objective) Component: 1) Public sector response Increase in knowledge Project Reports: (from Objective to Goal) among men and women of reproductive age (15-49 DHS Line ministries demonstrate years) that HIV can be commitment & capacity to prevented by condoms use implement effective and having sex only with activities. one faithful, uninfected partner. Females: 2000 Baseline composite measure from DHS of 54%; 2008 target of 70%. Males: 2000 Baseline composite measure from DHS of 69%; 2008 target Prevention activities lead to of 80%. behavior change. Reduction of 20% in reported discrimination in Workplace surveys the workplace. 2) Community, civil Scale of Proiect society, and private sector Increase of 50% in number Cost of utilizing VCT initiatives of communities which have CNLS services and its associated prepared sub-projects by stigma is reduced. 2008. Increase of 50% in the number of PLWHA Progress reports. associations and individuals participating in the project by 2008. Prevention Activities DHS Knowledge: Increase in percent of sexually active individuals who know that condoms can prevent transmission of - 43 - HIV infection. Femnales: 2000 baseline of 37% and 2008 target of 85%; Males: baseline of 65% and 2008 target of 95%. Health personnel adopt a positive attitude toward DHS PLWHA. Increase in the percent of rural women who report knowing that HIV can be transmitted by MTCT 2000 Baseline: 80% 2008 Target: 90% Treatment. Care. & TRAC Support Increase of 20% in the number of individuals of Presence of reliable drug reproductive age receiving supply mechanisms. VCT services by 2008. TRAC Increase by 25% in the number of health personnel trained in Syndromic Management for STIs by 2008. TRAC Increase in health center attendees referred for VCT services: Pregnant women: baseline unknown, 2008 target 50%; STI patients: baseline of 0.6% from a 2001 pilot study, 2008 target of 50%; OI patients: baseline of 2.1% from a 2001 pilot study, 2008 target of 75%; TB patients : baseline of 28%, 2008 target of 50%. MOH/TRAC - 44 - Percent of pregnant women attending ANC services who accept VCT services. 2002 Baseline of 80.7% and 2008 target of 95%. TRAC (Referral Laboratory). Percent of quality control samples that provide the same results at the National Laboratory as at the health center, with respect to VCT and syphilis screening. VCT: 2002 baseline of 90% and 2008 target of 99%. Communities are willing and capable of designing Progress Reports. and implementing activities to mitigate the impact of Mitigation the epidemic. Increase of 20% in the percent of PLWHA who have food and shelter by 2008. Increase of 20% in the number of PLWHA who receive HBC/CBC by 2008. Increase of 25% in the number of solidarity schemes involving widows and other vulnerable women 2008. Project reports and annual Increase of 25% in the workplans. number of communities providing care to orphans and vulnerable children by 2008. -45 - Community Sub-Projects Number of participatory workshops organized Number of districts receiving project subgrants Number of condoms distributed. Number of orphans and vulnerable children provided assistance. Number of income-generating activities organized. Quantity of educational materials produced and/or disseminated. Number of VCT training sessions held. Number of IEC/BCC related events organized. 3) Program Management, Project disbursements will Progress reports. Program management is Monitoring, and Evaluation increase sequentially each less effective than year of project expected. implementation. CNLS and MOH have conflicting responsibilities Number of program with regard to the project. management institutions (CNLS, CPLS, CDLS) submitting acceptable accounting and expenditure reports will increase between Year 2 and Year 5 of project implementation. -46 - Project Components / Inputs: (budget for each Project reports: (from Components to Sub-components: component) Outputs) 1) Public sector response US$7.0 million (22.0 percent) Management information Line Ministries will meet to system; develop policies and adopt Sectoral Assessments; strategies based on mutual Reports to CNLS. agreement with CNLS. 2/ Health Sector HI V/AIDS US$ 10.9 million (34 percent) Management information Solid public/private Care and Treatment system; Reports to CNLS partnerships are established for provision of comprehensive package of services 2) Community, civil society, US$10.7 million (33.4 Management information Civil society groups are and private sector initiatives percent) system; provided support to develop Reports to CNLS; Provincial work plans and proposals. and District Reports. 3) Capacity building, program Management information Intensive implementation coordination, monitoring and US$ 3.4 million (10.6 percent) system; support, as well as regular evaluation Project supervision and monitoring and supervision activity reports activities. -47 - Annex 2: Detailed Project Description REPUBLIC OF RWANDA: Multi-Sectoral HIVIAIDS Project The proposed project will support the implementation of the 2002-2006 HIV/AIDS National Strategic Plan. It includes four components: (1) public sector support; (2) HIV/AIDS care and treatment; (3) civil society support; and (4) program management, monitoring and evaluation. The design of the project has taken into account the difficult post conflict environment in Rwanda by: (a) planning for a longer than average implementation period to reflect the limited absorptive capacities in all sectors; (b) proposing a phased approach, whereby the initial years focus on building capacities and working with organizations which already have a proven track record and/or already have work plans ready for financing; and (c) placing a strong emphasis on capacity building at all levels in both the public and private sectors. To this end, activities funded under the four project components will be prioritized and sequenced in order to ensure that investments to strengthen capacity are initiated early and so that project activities complement and are harmonized with intiatives being funded by others (e.g., Global Fund support to scale up PMTCT, bilaterals, including the substantial HIV/AIDS program supported by USAID, and initiatives of the UNDAF Thematic Group on HIV/AIDS and Reproductive Health - that includes UNAIDS, WHO, UNICEF, UNFPA, UNIFEM, UNESCO) - which has developed a prioritized planning matrix to address such critical needs as strengthened capacity. Retroactivefinancing in an aggregate amount not exceeding US$0.6 million may be made in respect to thefollowing categories: goods, consultant services and training, and operating costs, on account of paymentsfor expenditures before the date of the Development Grant Agreement but after January 1, 2003. (according to OP 12.10). This retroactive financing is intendedfor the staffing of the project management unit, logistical support and provision of basic equipment to get the project off the ground By Component: Project Component 1 - US$7.00 million Public Sector Support The purpose of this component is to initiate, facilitate, and/or support the mainstreaming of FHV/AIDS activities into line mninistries with a view to bringing about desired changes in both individual and institutional behavior. The Rwandan public sector is expected to play a leadership role in terms of setting strategic directions and providing information. The project will support the building of capacity within line ministries and the implementation of lIlV/AIDS work plans to assist the public sector in fulfilling this mandate. The Govemment has elaborated an approach for sector-specific responses to the HIV/AIDS epidemic in the National Strategic Framework and Multi-sectoral Plan, which includes both capacity-building activities and sector-specific responses. Capacity-building aspects will be particularly relevant for those sectors not previously considered to have a direct role in combating 11WAIDS. The capacity-building aspects will include support for assessments that would provide a clearer understanding of the HIV/AIDS impact both within the ministry and its client population, and also provide guidance in the development of appropriate responses in terms of both content and scale. Line ministries will be expected to address, among other issues, the manner in which HIV/AIDS has affected their ability to provide services in their respective sector, planning and management of sector resources, human resources policies, and financial support from both government and donors to mitigate the impact of the epidemic on the respective sector. While the impact of the epidemic will differ across sectors, many -48 - issues will be common. Thus, the public sector work plans will support the following broad categories of activities: Capacity Building, Planning & Policy * Conduct sector impact assessments focusing on target groups. * Strengthen policy formulation with regard to HIV/AIDS with a focus on: (i) benefit packages for staff and dependents with respect to long-term care for this catastrophic, high cost illness; (ii) policies ensuring protection of human rights for PLWHA and mninimizing discrimination in the workplace; and (iii) gender-specific policies and programs affecting both mninistry staff and populations served. * Train staff in preparation, execution and monitoring of work plans. Prevention, Care, and Support Services * Information/education/communications (EEC) and behavioral change communications (BCC) campaigns targeted to ministry staff and their constituencies. * Promotion of condoms within ministry offices at national, provincial, and district levels. * Distribution to all staff of information regarding available health and social benefits to HIV sero-positive individuals. * Distribution of information regarding available health and social services, including location of VCT * sites. * Support mainstreaming of gender issues related to HLV/AIDS. A number of line ministries in Rwanda are already engaged in the fight against HIV/AIDS in their respective sectors and will benefit from project support to strengthen and scale up their programs. The Bank reviewed the activities of key line ministries and appraised their capacities to manage MAP funds. As discussed below, a number of line ministries have made good progress by establishing focal points, preparing analyses of the situation in their respective sectors, and initiating programmatic activities. Activities & Plans of Key Target Ministries Ministry of Defense Ministry of Education The Ministry of Defense (MOD) has put in place a strong The Ministry of Education has created a HIV/AIDS unit HIV/AIDS progran, located in the Health Services to coordinate HIV/AIDS related activities in the sector. Departrnent. The Health Services Department is placed This unit consists of a coordinator, 2 program officers and under the Secretary General, who reports to the Minister a management specialist funded by DFID. Its activities are f Defence. The Director of Health Services of the MOD upported by multiple donors, including World Bank, is a member of the CNLS and is the Chair person of the DFID, SIDA, and UNICEF. The unit coordinator is a CNLS Subcommission for Monitoring & Evaluation. The member of the CNLS. At the CPLS and CDLS levels there MOD has appointed a dynamic focal point to coordinate *s at least one representative of the local education system, activities. The Health service Departmant operates 3 often holding a key position. The unit has initiated hospitals and numerous health facilities located in the processes to release funds from the IDA-financed HRDP, military camps, which operate according to MOH norms but has not yet completed activities in their 2002 work nd sandards. These military facilities are open to plan. The unit has contracted with a consulting firm to soldiers and families, as well as to the general population. undertake an impact study that is planned to be completed Funding for the AIDS campaign in Defense has been by early 2003. The Unit is seeking to meet DFID received from various partners, including the recently Dreconditions for the release of further resources. The unit completed IDA-financed Health Project. is about to finalize preparation of an action plan that onsolidates support from the GOR and from multiple he MoD plans to establish a sectoral comrnission to donors into a single time-bound work program. A upervise and coordinate the AIDS campaign within the technical working group for HIV/AIDS activities in epartment, carry out advocacy, and build capacities to Education sector will also be created soon to support and - 49 - andle larger amounts of funds. A MoD sectoral plan has guide the HIV/AIDS coordination unit in strategic been developed and submitted to CNLS for approval. implementation of action plans. Proposed activities include: KAP surveys, EEC ampaigns, condom promotion and distribution, While the priority in the short run is to use the funds prevention and expanded treatment of STIs, treatnent of Iready existing, the Ministry of Education has requested pportunistic infections, and VCT. TheMoD also plans to dditional support from MAP resources to finance a pen a PMTCT unit and 5 new VCT centers, which will ituation analysis of health status of school children. The require additional resources for training, purchasing drugs nalysis would assist in designing a comprehensive and and medical supplies, and monitoring & evaluation. ost-effective school health program and would include a: Finally, as a new type of activities to be addressed, the sychosocial assessment of the children to determine the oD is interested in developing microprojects aimed at scope and impact of abuse and post-conflict trauma on the revenue creation for HIV affected families and orphans. hildren; prevalence of infectious diseases and/or parasites Activities in support of the MOD will be channeled and other common diseases among school children; ertically through the military chain of command. In the utritional status and anthropometric measurements; and a Future, there will be increasing levels of cooperation tudy of Knowledge, Attitudes, Practices and Behavior between Defence units (conunands, brigades, batallions, (KAPB). The Ministry has also requested assistance for nits) and CPLS, CDLS and cells as those structures the treatment of HIV-infected teachers, which would be develop. It is expected that MAP funding would be rovided through the Ministry of Health. The selection of rovided to assist the MoD to scale up activities arget groups to be provided treatment under an eventual upported under the recently completed Health Project caled up ARV therapy program will need to be addressed and to pilot new approaches. by the govermment. Ministry of Gender and Promotion of Women The Ministry of Local Government and Social Affairs he MIGEPROFE has a division of Advocacy for Gender he Ministry of Local Govemrnment and Social Affairs which is the coordinating unit for the HIV/AIDS (MINILOG) is responsible for decentralization and has ampaign. The Division Chief is also a CNLS esigned a comprehensive community development policy. onunissioner. The focal point is the director of the ommunity Development Commnittees (CDCs) have been Women's Promotion section at MIGEPROFE. The central stablished to coordinate planning, implementation, unit is working with the networks of women's monitoring and evaluation. Projects originate from rganizations (structures organisationnelles desfemmes), community members and are being implemented under which are organized in commnittees at the provincial, upervision of the communities themnselves. Since 1998, district, sector and cell levels. These networks have an IDA-financed project, the Community Reintegration formed a National Councilfor Women (CNF) whose nd Development Project (CRDP), has piloted this tatutes will be approved soon. The CNF will be the approach in 12 districts, covering about 5 provinces. Other ational coordinating body for all women's associations. DCs are testing similar participatory approaches with n "umbrella" organization entitled "For Women All Fmancing from other donors. Each CDC has been ogether (Pro Femmes Twesse Hamwe) has been allocated roughly US$90,000 equivalent. The goal was to reated, grouping 35 women's associations. This trengthen capacities of community-based organizations Federation is aimed at strengthening capacities and d local governments to prepare and implement oordinating activities of smaller associations. The ommunity development programs. Experience to date has Ministry is about to finalize its HIV/AIDS 2003-2007 een extremely positive. Evaluations and audits have strategic plan and its plan of actions for 2003, both to be shown that CDCs have proven capable to handle ubmitted to the CNLS for approval. The plans have been rocurement and financial management functions and to repared in a participatory manner at decentralized levels. uport communities to carry out their activities. The Bank he activities proposed consist mainly in IEC & s currently discussing with the government the ommunity mobilization and sensitization, creation of ossibilities for scaling up this successful experience to emand for prevention and medical care, initiation of ther districts in Rwanda, and to expand the level of income generating micro projects, training and esources for communities which have been involved in the oordination. Women's organizations are to be nitial pilot. The MAP operation would piggy back on to epresented in the CPLS and CDLS structures. They are his relatively successful pilot to provide funds for lso represented in the Community Development HV/AIDS related activities. ommittees that have been created nationwide and are perating in roughly half the districts. The Ministry, as well as women's organizations and networks, are very weak in terms of institutional capacities. - 50 - Project Component 2 - US$10.90 million Health Sector HIV/AIDS Care and Treatment As was emphasized in the main text of this document, the Ministry of Health will play a lead role in the Rwandan response to HIV/AIDS,. The Rwanda MAP will be supporting many of the MOH's important initiatives, in collaboration with the Ministry's other development partners. The MAP team worked closely with the Treatment and Research AIDS Center (TRAC), the Ministry of Health's division responsible for HIV/AIDS issues, in addition to external partners in determining how MAP resources could best address the remaining gaps in the health sector-specific contribution to both the National Multisectoral Plan and Strategic Framework. The overall objective of this component is to contribute to a reduction in morbidity and mortality from HIV/AIDS, STIs, and opportunistic infections (such as tuberculosis). This will be done by increasing the demand for prevention, care, and support services, improving the quality and accessibility of these services, and increasing the capacity of the health sector to respond effectively to the growing challenges of a maturing HIV/AIDS epidemic. The Ministry of Health also is expected to take the leadership role in improving the handling and disposal of HiIV/AIDS infected materials, in line with the strategic orientations of the waste management plan which was elaborated as part of the preparation of the Rwanda MAP. As was also mentioned previously, while the Ministry of Health will be able to include in its annual work plan a full range of activities, the focus of the project will be on those activities not covered by other donors or by the Global Fund. Rwanda is receiving funding from the Global Fund to establish 117 integrated VCT sites at health centers, enabling the provision of an integrated package of HIV/AIDS-related services, including treatment for OIs and PMTCT. Given that the Global Fund and a number of other development partners are providing technical and financial resources at the health center level, the MAP will be complementing these national efforts by focusing much of its health-sector specific efforts at the district-level. The following interventions are proposed under this project: Improved capacity among health professionals at all levels During its initial years, the project will place the highest priority on strengthening national capacity to respond to HIV/AIDS, to complement activities to be supported under the Global Fund. Increasing the capacity of the health sector is central to these efforts. As a result, the project proposes to support a comprehensive and integrated program of in-service and on-the-job training. * STI & HIVIAIDS Case Management The project's health-sector capacity building focus would include training on HIV testing techniques, diagnosis and treatment of opportunistic infections, AIDS case management, syndromic and laboratory diagnosis of STIs, home and community-based care, blood and injection safety, as well as counseling skills, among other key areas. This program will place particular emphasis on adressing training (and service delivery gaps) in the diagnosis and treatment of STIs using the the Syndromic Management approach. This priority results from the currently limited national coverage of this critical intervention, particularly with respect to women's health services. * Diagnosis, Care & Support The project intends a strong focus on care issues by training a core staff at each of Rwanda's 45 district hospitals on effective care and support of PLWHA. It is anticipated that these "prestataires" would serve as resource persons and trainers for other staff. The project also plans to support health workers, working jointly with NGOs, to develop a functional home- and community-based care program for PLWHA, which will entail the establishment of appropriate standards, in-service training of health workers, provision of learning aids, and basic medical and - 51 - pharmaceutical commodities (essential drugs, gloves, condoms, etc.) for the pilot activities. The project will be responsible for supporting the training of laboratory technicians in all districts hospitals in Rwanda. It is anticipated that information regarding universal precautions procedures will be addressed in these sessions, particularly with respect to the handling of blood and other clinical specimens. * Logistics Management & Human Resourcess The project will also support logistics rnanagement training for MOH staff, especially at the facility level, with respect to the supply of drugs and other essential medical commodities for these programs. In an attempt to address the country's continuing serious human resource constraints, the project may enable the recruitment of district-level technical staff to support the more effective delivery of district-level services. The Ministry of Health will prepare a proposal, including the justification and rationale for doing this as well as the government's proposal for integrating this personnel into the public system. The project also proposes support for HIV/AIDS prevention programs for the workplace, as such targeted IEC/BCC campaigns and related trainings, which would reduce the vulnerability of health professionals to behavioral and occupational HIV/AIDS-related risks. Improved availability of drugs to treat STIs and Ols and related commodities * The project will finance the purchase and distribution of basic essential drugs and related diagnostics to treat HIV/AIDS-related opportunistic infections and STIs. The project will be investing substantially in the procurement of HIV test kits for all district hospitals, where VCT service availability remains limited. The GFATM proposal only provides for test kits and related supplies at the health center level. The project will include rapid HIV tests for VCT services, including a test for screening, confirmation, and tie-breaker tests, as nieeded. Similarly, the project proposes to finance the requisite drugs for the treatment of OIs for district hospitals, thereby enabling the government to subsidize and expand access to these relatively costly drugs. This drug procurement will primarily include drugs for the treatment of the most comnmon Ols, including pulmonary disease, fungal infection, gastroenteritis, diarrhea of unknown origin, and skin diseases. The project proposes to finance STI drugs for the health districts that are not already covered by other sources, which'are estimated to be roughly 25 percent of the total health districts. The project will also fund antiretroviral drugs to be used at 12 learning sites where the provision of ART will be initiated under the MAP. * Depending on future funding gaps, this subcomponent may also include the financing of syphilis test kits for use in antenatal settings. The project will also be financing necessary reagents to perform confirmatory tests, as well as the equipment necessary to maintain these supplies (e.g. refrigerators, etc.). Medical supplies such as gloves, disposable syringes, tubes, etc. related to HIV testing, syphilis screening, and treating Ols will also be procured, as needed. Depending on future needs assessments conducted by the Ministry of Health, the project would be able to finance the procurement and distribution of condoms for health facilities (VCT/MTCT/OI/STIIRH/FP sites). Future condom procurements for the Ministry of Health would be coordinated with the strong marketing program under implementation in Rwanda to ensure complementarity of efforts and to avoid stock outs in condom supplies. Rehabilitation of health centers to enable improvement in the treatment of STIs, HIV/AIDS, OIs, and related health care needs * The project will support the rehabilitation of existing health facilities to enable the establishment of - 52 - more sites where clients would be able to access confidential and user-friendly services, ranging from VCT to the treatment of Ols. The actual rehabilitation needs will vary considerably, ranging from the partitioning off a large area into small (private) counseling rooms to the construction of an add-on rooms to house these services. The Ministry of Health will carry out a rapid assessment of these needs and determnine how facility rehabilitation/remodelling will be phased in during the life of the project, particularly taking into account the establishment of VCT sites under the Global Fund. Improved blood safety. * The MAP will support the strengthening of blood banks including the procurement of needed laboratory equipment and basic supplies such as blood bags. It will also support the establishment of clear quality assurance standards to ensure blood safety at all levels. In-service and on-the-job training on blood safety and transfusion techniques will also be supported. The project will additionallv finance logistical support to enable the more efficient functioning of the system. Operational Research * The MAP will support a number of priority studies related to the more effective treatment of HIV/AIDS, STIs, and Ols. Operational research on alternative clinical management models and drug resistance among STI and HlV/A1DS clients receiving treatment services will likely comprise most of this research program in the initial years of the project. * Guided by the MAP II policy on the potential utilization of IDA assistance for antiretroviral programs, this project will support a pilot to test the feasibility of introducing ARV therapy in Rwanda. This pilot has been designed based on the assessment carried out by the Center for Disease Control (CDC), in close collaboration with other national and international technical partners. The objective of such a pilot would be to explore possibility for support to a program that would increase access to ARV therapy in Rwanda through the decentralized structures of the Ministry of Health while providing an opportunity for intensive learning of how gaps in capacity could be addressed and the development of standards of care. Project Component 3 - US$ 10.70 million Civil Society Support In order to more fully engage and empower civil society organizations in the national response, the Rwanda MAP will support a component for channeling funds to these stakeholders on a grant basis. The civil society component will support HIV/AlDS work plans of community groups, youth groups, women's groups, associations of People Living with HIV/AIDS (PLWHA), non-governmental organizations (NGOs), religious groups, labor unions, and private enterprises. Community-driven local initiatives, funded through these grants, will contribute to the improvement of the welfare of cornmunities by increasing their access to resources to prevent further spread of HIV and to address the impact of the epidemic on individuals and households. These sub-projects will be prepared, implemented, and managed by beneficiary communities and stakeholders. The HIV/AIDS community grants will include the following types of activities: * Preventive measures to facilitate behavior change. Examples of possible sub-projects include peer programs, theatrical productions, social marketing of condoms through community based distribution (CBD) schemes, informal education programs for out-of-school children, awareness and mobilization activities to be supported under the youth groups against AIDS (FOJAS), and IEC messages to be disseminated by faith-based groups. * Social andfinancial support for orphans and vulnerable children who will be a key target group to be - 53 - supported under this component. Possible assistance programs will include psychosocial support, school fees, school uniforms, and health care. A child needs assessment survey, to be carried out with support from a Japanese grant, will assist NGOs and cornmunity groups to identify the needs of young children affected by the epidemic in their respective communities and to design appropriate remedial actions. * Training programs for comrmunity volunteers, counselors, and home based care-givers. o Support to associations of PLWHA, in addition to seed funding to start income-generating activities to those infected or affected by H[V/AIDS. * Support demand-side subsidies to address the financial obstacles faced by poor people seeking testing, care and treatment for opportunistic diseases associated with HIV, PMTCT, and for eventual ARV treatment as it scales up. Demand-side financing could be in the forrn of vouchers to cover fees for testing or drugs, or partial/complete subsidies for poor families to join the community financing pre-payment schemes (mutuelles). A study (see box below) will be undertaken to guide the design of these types of interventions which will be subsequently piloted and assessed during the first two years of the project. The civil society component will be implemented through two modalities. The first will involve an 'on-granting' arrangement, whereby an NGO with substantial capacities and a strong track record will provide sub-grants to smaller NGOs and associations to strengthen and/or scale up their activities. The second modality will consist of supporting cross-cutting community HIV/AIDS initiatives under the guidance of local Conmmunity Development Committees which would work hand in hand with the CPLSs and CDLSs. These modalities will be tested during the initial years and scaled up depending on results attained. The details of these arrangements are described below under the institutional and implementation section (Section 4). - 54 - Demand-side Subsidies In January 1999, the Rwandan Ministry of Health with the technical and financial assistance of the Partnerships for Health (PHR) project and the close collaboration with the local population initiated the design and development of prepayment schemes for basic health care. The design and implementation of insurance modalities and management features were discussed and agreed upon during 28 district level workshops, which were attended by community and health care representatives, and in a series of community gatherings with the local population. As a result of this on-going discussion between the central and local level, insurance features were designed, the legal, contractual, and financial tools were developed and workshop participants were trained and prepared to own and manage their 54 mutuelles, each entering into partnership with a health center. Membership covers a basic health care package including deliveries, essential drugs, and curative and preventive care services provided by nurses in a "preferred" health center; and ambulance transfer to the district hospital, where a limited package is covered with health center referral. Members pay a ioo RWF (USD 0.30 in 1999) co-payment for a health center visit. Individuals and households who would like to be insured pay at the time of enrollment an annual premium of RWF 2,500 (USD 7.50 in 1999) per family of up to 7 persons. The funds are managed by the mutuelle executive bureau, and owned and pooled by all members. At the end of their third operational year in June 2002, the 54 prepayment schemes counted almost 134,000 members, corresponding to about 15 percent of the rural population in the districts of Byumba, Kabgayi and Kabutare. Results suggest that the current prepayment schemes respond to equity objectives, as people across all monetary consumption quartiles and independent of their cattle ownership have a similar probability to enroll. Moreover, some poor families have benefited from subsidized enrollment, such as in Kabutare, where the local church financed prepayment schemes enrollment for about 3,000 orphans and widows with their family members. The equally poor non-members cited poverty as the main reason not to enroll in prepayment schemes, suggesting that providing targeted, demand side subsidies to these households would remove the financial barrier to accessing health services. Of immediate concern are the poorest households, who are most likely headed by a woman, an older person, or an illiterate household head. Results to date have shown that in a low-income context, revenue generated from members together with cost control measures may not be enough, and public financing sources are needed to reach equity, efficiency and sustainability objectives. The prepayment schemes need help in scaling up their membership and range of services to a universal scheme with all services covered at the district level. Without sustained technical and financial assistance, the schemes might not survive, simply because they serve a population who is too poor to finance its own medical service use, and who needs organizational capacity building to develop the necessary technical skills to own and manage their mutuelles effectively. The proposed study has two objectives: (i) to design and cost out the modalities for providing demand side subsidies through the MAP to assure enrollment of the poor in the pre-payment schemes at a reduced premium level; and (ii) to explore the feasibility of introducing & testing other demand side financing options in light of local priorities and constraints. The proposed consultancy would, inter alia, identify different options, assess the feasibility, and if appropriate, define the institutional and operational parameters for financing such demand-side subsidies through the MAP and other IDA operations. The viability of the different options would be assessed against their ability to allow targeted groups to overcome financial barriers in accessing a pre-defined basket of health care services, as well as determine, where applicable, their potential for mobilizing a supply-side response from private providers of health care services. - 55 - bemand-side Subsidies (cont..) The consultants would identify different forms of demand side subsidies, including payment of premiums of pre-payment scheme members, and related strategic design and implementation issues. This would include the following: different targeting approaches, program administration, and strategies to mitigate issues of adverse selection, moral hazard, low redemption rates, and trafficking. These different options would then be assessed vis-a-vis the financial barriers that the torgeted groups face in accessing specific types of health services. The proposed options will also be assessed in light of the implementation capacity required locally to administer and oversee the program, including activities related to targeting, Information and education of targeted groups, distribution and redemption of the vouchers, funding and reimbursement of service providers under certain exemption, health card or voucher related schemes, and monitoring and evaluation of provider performance and other intermediaries involved in program implementation. Where applicable, the consultants will also evaluate each option's potential to induce a supply side response from for-profit, non-profit or mission-based providers of health care services. Lastly, the consultants will prepare a program budget, timetable and work plan for implementing and evaluating the results of a specific pilot program featuring demand-side subsidies. The consultants will work closely with local counterparts to ensure buy-in of proposals. -56 - Project Component 4 - US$3.40 million Program Management, Monitoring and Evaluation Program Management, Coordination & Capacity Building This component will provide financial and technical support to the Executive Secretariat of the National HIV/AIDS Commission (CNLS) to coordinate the national program, as well as the project activities. It will also provide progressive support to the provincial (CPLS) and district-level entities (CDLS) to assist them to coordinate local activities, carry out advocacy and facilitate social mobilization. This will involve the provision of technical assistance, training and operating support to complement funding to be provided by the government. The phasing of these activities at the decentalized level will occur according to a set of readiness criteria agreed upon between the government and IDA and spelled out in the operational manual. While all provinces will benefit from capacity building, during the initial years the project will initiate support for HIV/AIDS activities in those provinces/districts which have been supported under the Community Development and Reintegration Project and already have established procedures and mechanisms for channeling funds to communities. The component will also support activities that are to be coordinated centrally by the CNLS, which involve economies of scale. This could include organization of training workshops and capacity building activities for CPLS, CDLS, NGO/CBOs, representatives of line ministries, and other key stakeholders; carrying out national IEC campaigns; developing requisite guidelines, and other activities necessary to coordinate and stimulate the national response. Tthe CNLS may also commission studies on topics of special interest such as how to promote income generating activities and how to strengthen home-based care of patients. Monitoring & Evaluation CNLS, in collaboration with its partners, will be responsible for the overall monitoring and evaluation of program progress. The project will support, as necessary, activities to strengthen the monitoring and evaluation of the program, as recommended by a forthcoming assessment to be carried out with support from the USAID-funded MEASURE Project. This could include financial and technical support for: carrying out staff training, and carrying out studies and surveys (e.g. Demographic and Health Survey, Behavioral Surveillance Survey, Beneficiary Assessments, lP6/IP7, Child Needs Assessments), and organizing workshops to disseminate results. Project Coordination This component will also provide support for the establishment of the Project Management Unit, in order to facilitate the programming, coordination and monitoring of project activities. To this end, the project will support the deployment/recruitment of skilled and experience manpower to staff the PMU, technical and financial audits, logistic support to facilitate coordination and monitoring, and the organization of meetings of the steering committee and annual project reviews. -57 - Annex 3: Estimated Project Costs REPUBLIC OF RWANDA: Multi-Sectoral HIVWAIDS Project : -- -; ;. - Local Foreign - Total- *| - .Project Cost By Component -US $million US $million US $million Public Sector Support 6.32 0.22 6.54 Civil Society Support 9.97 0.09 10.06 EIV/AIDS Care and Treatment 2.89 6.40 9.29 Program Management, Monitoring and Evaluation 1.79 1.31 3.10 Total Baseline Cost 20.97 8.02 28.99 Physical Contingencies 0.30 0.72 1.02 Price Contingencies 1.34 0.65 1.99 Total Project Costs' 22.61 9.39 32.00 Total Financing Required 22.61 9.39 32.00 . - .. ,. , ,Local Foreign Total J - .-n - . Project Cost By Category - . . -US $miilion US $rnillion US $miliion Works 0.57 0.14 0.71 Goods 1.62 6.49 8.11 Consultant services & training 2.08 0.82 2.90 Work plans: public sector 4.85 0.00 4.85 Grants: private sector 9.00 0.00 9.00 Operating costs 2.85 0.57 3.42 1. Physical Contingencies 0.30 0.72 1.02 2. Price Contingencies 1.34 0.65 1.99 Total Project Costs 22.61 9.39 32.00 Total Financing Required 22.61 9.39 32.00 Identifiable taxes and duties are 0 (US$m) and the total project cost, net of taxes, is 32 (US$m). Therefore, the project cost sharing ratio is 0% of total project cost net of taxes. - 58 - Annex 4 REPUBLIC OF RWANDA: Multi-Sectoral HIV/AIDS Project As the project is part of the Multi-Country lIV/AIDS Program for the Africa Region (Report No. 20727 AFR) no specific economic analysis was carried out. The economic analysis contained in the PAD for the MAP I operation contains the overall economic justification and underpinnings for the Rwanda MAP. - 59 - Annex 5: Financial Summary REPUBLIC OF RWANDA: Multi-Sectoral HIV/AIDS Project Years Ending Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Total Financing Required Project Costs Investment Costs 4.0 5.7 7.6 7.8 6.9 0.0 0.0 Recurrent Costs 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Total Project Costs 4.0 5.7 7.6 7.8 6.9 0.0 0.0 Total Financing 4.0 5.7 7.6 7.8 6.9 0.0 0.0 Financing IBRD/IDA 3.8 5.4 7.3 7.5 6.6 0.0 0.0 Govemment 0.2 0.3 0.3 0.3 0.3 0.0 0.0 Central 0.0 0.0 Provincial 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Co-financiers 0.0 0.0 0.0 0.0 0.0 0.0 0.0 User Fees/Beneficlaries 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Other 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Total Project Financing 4.0 5.7 7.6 7.8 6.9 0.0 0.0 Main assumptions: -60 - Annex 6(A): Procurement Arrangements REPUBLIC OF RWANDA: Multi-Sectoral HIV/AIDS Project Procurement General The current public procurement system in Rwanda was put in place in 1997. Since then no Country Procurement Assessment Review (CPAR) for Rwanda has been carried out. To date, the procurement regulation is yet to be confirmed by appropriate legal support as the present system is based on a cabinet meeting decision creating the National Tender Board and directives issued by this institution. A reform and formalization of Rwanda's procurement system is currently underway. By December 2002 this reforn is expected to result in formal procurement regulations, including standard bidding documents based on the Bank's standard documents. Experience to date has found that procurement procedures in Rwanda do not conflict with Bank guidelines. Furthermore, Rwandan procurement practices allow IDA procedures to take precedence over any contrary provisions in the national regulations. Guidelines Procurement of goods and works required to be financed from the proceeds of the grant shall be governed by the Guidelines for Procurement under IBRD Loans and IDA Credit, published in January 1995, and revised in January and August 1996, September 1997 and January 1999. National Competitive Bidding will be carried out in accordance with Rwandan procurement regulations and as stipulated in an Operational Manual, acceptable to IDA. The procurement procedures, to be outlined in the Operational Manual, will ensure transparency, efficiency and fair practice. More specifically, the procedures will involve: (i) advertising the bids in national newspapers which have a wide circulation; (ii) stipulating clearly the bid evaluation and award criteria; (iii) giving bidders sufficient response time (i.e. minimum four weeks) to prepare and submit bids: (iv) awarding bids systematically to the lowest evaluated bidder rather than in an arbitrary manner; (vi) allowing all eligible bidders, including foreign bidders, to participate and; (vi) not applying domestic preference margins to domestic manufactures and suppliers. Consultant service contracts financed by the grant will be procured in accordance with the Bank's Guidelines for the Selection of Consultants by World Bank Borrowers (January 1997, revised in September 1997, January 1999 and May 2002). The World Bank's Standard Request For Proposal (SRFP) and forms of contracts (e.g. lump sum; time based and/or simplified contract for short-term assignments and individual consultants) will be used, as needed as well as the sample evaluation reports for the selection of consultants. Advertising A General Procurement Notice (GPN) will be prepared and issued upon board approval in the United Nations Development Business listing all goods contract above US$ 150,000 equivalent and contracts for consultant services above US$ 100,000 equivalent to obtain expressions of interest and to draw up a list of potential firms and candidates for short lists. Sufficient time (i.e. not less than thirty days) will be allowed for the preparation of the short lists. The GPN will be updated on a yearly basis as long as ICB for goods and consultant contracts exceeding the above-mentioned amounts are included in the annual procurement plan. Specific Procurement Notices (SPN) will be required for all goods -61 - contracts procured by ICB and NCB. SPNs will be published in national newspapers of wide circulation and internationally for large contracts (ICB). Procurement Capacity Assessment Procurement activities under the project would involve the following key actors: (i) the Project Management Unit (PMU) that will be located within the CNLS; (ii) the National Tender Board (NTB); (iii) CAMERWA, the Rwandan drug procurement agency (Centrale d'Achat des MA9dicaments); (iv) line rninistries and twelve Provincial AIDS comrnmissions (CPLS); and (v) NGOs, private enterprises and community-based organizations. The government is establishing a Project Management Unit, having recruited a Project Manager and Financial Management Specialist. While the recruitment of the Procurement Specialist was running on a parallel track a candidate has not yet been identified and the position has been re-advertised. It was therefore not possible to assess the procurement capacities of the PMU. The procurement assessment has focused on the National Tender Board and CAMEIRWA. During negotiations it was agreed with Rwandan authorities that the selection of the Procurement Specialist would be completed by end March. In the meantime, the CNLS has used its own Procurement Specialist to assist in handling procurement matters and in preparing the groundwork for the start up of the Multi-Sectoral FHV/AIDS Project, including the preparation of the procurement section of the operational manual. The National Tender Board was created in 1997. It has the overall responsibility for procurement of contracts over Rwanda francs 3 million to be awarded by public entities. The formalization of NTB's status by a legal document (law or decree) has been pending for more than three years. While this issue needs to be resolved in the near future, it has not hindered the handling of procurement matters under IDA-funded projects in Rwanda. To date, the NTB has established a set of guidelines that are being used effectively by public agencies in Rwanda. The NTB is staffed with relatively young staff, who are well educated but lack significant work experience. Staff dealing with IDA projects have attended procurement-training course organized or supported by the Bank. The NTB has made significant progress in strengthening knowledge of Bank procurement procedures and guidelines over the past three years. However there is still room for improvement. In this regard, the NTB needs to focus on: (i) strengthening procurement planning in public sector agencies; (ii) improving procurement filing and documentation systems in the public sector; (iii) reducing delays in the procurement process; and (iv) ensuring consistency and transparency in procurement decisions. The project will provide support aimed to address these weaknesses and to strengthen overall procurement capacities of institutions to benefit from this operation. To this end, the project would finance the following activities: o Training of NTB staff so that they may serve as trainers for in line ministries staff and NGO officers; O Recruitment of a short-term consultant to assist different institutions to establish adequate procurement plans and develop mechanisms for monitoring the implementation of procurement activities; and o Hiring of a short-term consultant to design and set up an adequate procurement filing system. The government has selected CAMERWA as the procurement agent for drugs and medical supplies to be procured under the HTV/AIDS Multi-Sector Project. CAMERWA is the national drug procurement and distribution agency. CAMERWA was transformed from a public sector entity into a - 62 - non-profit organization in December 1998 with the assistance of the IDA-funded Health Project. It has the overall responsibility for the procurement of low cost, high quality generic drugs and other medical supplies for the public sector in Rwanda. To date, this relatively young institution has proven effective in fulfilling its mandate. Since 1999, CAMERWA has efficiently handled at least four major ICB procurements annually, of which each one was valued at between US$1.0 to 2.0 million. The assessment carried out by the Bank mission concluded that CAMERWA is able to handle all procurement related to drugs and medical supplies under this operation. Line ministries and Provincial HIV/AIDS Commissions (CPLS) will have the responsibility for handling contracts estimated to cost less than US$10,000, which would be procured through national shopping. Even though this procurement method is relatively simple, a special effort will need to be made to strengthen knowledge of procurement, particularly amongst the institutions that have never worked with IDA operations in the past. To this end, it was agreed that a short-term procurement consultant would be hired by the PMU to provide intensive training to staff of line ministries and CPLS. NGOs, civil society groups and private enterprises proposing sub-projects will conduct their own procurement in compliance with the rules and guidelines spelled out in the Operational Manual. The PMU will be responsible for assessing the capacity of these private sector groups to handle procurement activities. NGOs, civil society groups, and private enterprises which do not satisfy requirements to handle their own procurement will have to seek assistance from qualified consultants. Based on the procurement assessment carried out during the pre-appraisal mission, the overall risk assessment is high, mainly due to the following factors: (i) the PMU is not yet staffed with experienced and qualified procurement staff and; (ii) the tools needed to handle procurement matters (e.g. standard bidding documents) are still under preparation. Therefore, the project is not eligible for PMR-based disbursement on procurement reporting grounds. However, the situation will be reassessed annually in order to take stock of progress during implementation of the project. Procurement Plan During negotiations it was agreed that the procurement plan would be revised by grant approval and completed by effectiveness. Likewise, it was agreed that by November 1 of each year, a procurement plan for the next year would be submitted by the Project Management Unit for IDA review and approval. The procurement plan will be updated at least once a year and a progress report will be forwarded to IDA, documenting status of procurement activities and identifying problems and remedial actions. The procurement plan does not include sub-projects to be implemented by NGOs, civil society organizations and private sector enterprises, as their demand driven nature makes it difficult to finalize procurement plans at this stage. However, the appraisal document of each approved sub-project will include a procurement schedule detailing what is to be procured and which methods are to be used. Procurement implementation arrangements The PMU will be responsible for all procurement activities except for those activites to be carried out under the civil society component. Thus the PMU will be responsible for: (i) preparing and updating procurement plans; (ii) drafting bidding documents and assisting implementing agencies in the preparation of their own documents; (iii) participating in bid openings and evaluations; and (iv) assessing the capacities of NGOs, private sector enterprises, and civil society organizations to handle - 63 - procurement under their sub-projects; and (v) monitoring contract implementation and admninistration. Given the relatively modest amount of civil works activities, there is no need to recruit permanent staff for supervising these activities, the PMN will hire a qualified consulting firm on a time-based contract for this purpose. This firm would be responsible for the supervision of all civil works that will be financed under the project. It will hire engineers for civil works design, participate in the recruitment of contractors, and monitor the civil works perforned by engineers and contractors. Line ministries and the CPLS will be responsible for the procurement of off-the-shelf goods or standard specification commodities required to execute their annual work plans and estimated to cost less than the US$10,000 equivalent per contract. All other procurement included in their work plans would be conducted by the PMU with the involvement of NTB. For goods, services and civil works estimated to cost more than US$10,000 equivalent, the procurement process will be under the responsibility of the NTB. To this end, the NTB will review bidding documents prepared by the PMU, conduct bid openings, and award contracts. The NTB will not be involved in procurement activities under sub-projects implemented by NGOs, private enterprises and civil society organizations. The procurement of drugs and medical supplies will be carried out by the CAMERWA. The NTB will work closely with the PMU on strengthening of procurement capacities of line rninistries as well as NGOs and civil society organizations. Procurement under the civil society component would be handled by the respective organization with the exception of items to be procured in bulk such as drugs, condoms and medical supplies to be procured through CAMERWA or computers to be procured through the PMU. Applications for sub-projects would be sent to the CNLS and the PMU for review and approval. The sub-projects will be assessed, including the capacity of the respective organization to handle procurement activities in accordance with the guidelines described in the Operational Manual. Procurement methods (Table A) Civil Works No ICB is expected for civil works contracts. Nevertheless, in the event that a large civil works activity is introduced at a later stage, 1CB would be used for civil works estimated to cost more than US$500,000 equivalent. Civil works estimated to cost between US$50,000 and $500,000 equivalent per contract up to an aggregate of US$ 620,000 may be awarded by National Competitive Bidding (NCB) in accordance with the provisions of paragraphs 3.3 and 3.4 of the Bank Guidelines Small works would be limited to remodeling/refurbishing of existing infrastructure such as health facilities, youth centers, and communal meeting facilities. These small works estimated to cost less than US$50,000 equivalent per contract up to an aggregate of US$ 150,000 may be procured on the basis of quotations obtained from at least three qualified contractors in response to a written invitation lauched by NTB. The written invitation would include a description of the works, basic technical specifications, completion date and the plan of works, as necessary. The contract may be awarded to the firm which offers the lowest quotation, provided that the bid is substantially responsive to the conditions specified in the written invitation. A simple format for the invitation would be included in the Operational Manual. Goods The total cost of goods contracts is estimated at US$9.5 rmillion equivalent. It would include items such as drugs, H1V test kits, condoms, laboratory equipment, vehicles, computers, office equipment, furniture, and EEC materials. To the extent possible, goods would be combined in packages estimate to cost US$100,000 equivalent or more and would be procured through International -64 - Competitive Bidding (ICB) procedures, using IDA Standard Bidding Documents. Contracts for drugs and medical supplies estimated to cost less than US$300,000 equivalent up to an aggregate of US$ 0.75 million may be procured through limited international bidding. This method will be used in cases where there are only a few known suppliers and with Bank prior approval. Contract for goods estimated to cost less than US$100,000 equivalent up to an aggregate of US$ 0.4 million would be procured through National Competitive Bidding (NCB). Procurement for readily available off-the-shelf goods that cannot be grouped or standard specification commodities for individual contracts estimated to cost less than US$50,000 equivalent up to an aggregate of US$0.5 million, would be procured under National Shopping or International Shopping procedures, as described in paragraph 3.5 and 3.6 of the Bank Guidelines and June 8, 2000 Memorandum-"Guidance Procurement Note on Handling Procurement under Shopping Method". Goods which must be purchased from the original supplier to be compatible with existing equipment, or, are of a propriety nature up to an aggregate amount to to exceed US$200,000, may, with the Association's prior agreement, be procured in accordance with the provisions of paragraph 3.7 of the Guidelines. Contracts for goods estimated to cost less than US$150,000 equivalent may be procured through the United Nations Agencies (IAPSO, UNICEF, UNFPA, WHO) in accordance with the provisions of paragraph 3.9 of the Guidelines. Procurement under the civil society component Sub-projects financed under the civil society component would comprise a broad spectrum of activities to be undertaken with direct participation and financial contribution of the respective organizations. It is not possible to determine the exact mix of goods, small works, and services to be procured under these sub-projects due to their demand-driven nature. Funding for these activities would be in the form of grants. Therefore, the types of activities to be financed under sub-projects and their procurement details would depend on the needs identified by the respective organization. The goods and services would be procured following simplified procurement procedures as described in the Operational Manual. The manual to be used by the project will be based on the Bank Guidelines for Simplified Procurement and Disbursement for Community-Based Investments (February 1998). - 65 - Table A: Project Costs by Procurement Arrangements (US$ million equivalent) -. -:_,-'E - 'e--.' :' . ,, , Procurement Method -. - x t tegorby - lC - - OB Other N.B F. Total Cost 1. Works 0.00 0.62 0.15 0.00 0.77 (0.00) (0.56) (0.14) (0.00) (0.70) 2. Goods 8.45 0.40 0.70 0.00 9.55 (8.45) (0.40) (0.70) (0.00) (9.55) 3. Services 0.00 0.00 3.21 0.00 3.21 (0.00) (0.00) (3.14) (0.00) (3.14) 4. Public Sector Work Plans 0.00 0.00 14.70 0.00 14.70 and Private Sector Grants (0.00) (0.00) (14.18) (0.00) (14.18) 5. Operating Costs 0.00 0.00 3.77 0.00 3.77 (0.00) (0.00) (2.93) (0.00) (2.93) Total 8.45 1.02 22.53 0.00 32.00 (8.45) (0.96) (21.09) (0.00) (30.50) " Figures in parenthesis are the amounts to be financed by the Bank Grant. All costs include contingencies. vIncludes civil works and goods to be procured through national shopping, consulting services, services of contracted staff of the project management office, training, technical assistance services, and incremental operating costs related to (i) managing the project, and (ii) re-lending project funds to local government units. Note: N.B.F. = Not Bank-financed - 66 - Consulting services and training Consulting services financed under the IDA grant would be for HIV/AIDS training, information, education, communication (EEC), applied research, financial management, monitoring and evaluation, information dissemination, auditing and accounting; and strengthening of institutional and technical capacities. Contracts estimated to cost US$100,000 equivalent or more would be procured through Quality-and Cost-Based Selection (QCBS). The contracts for services estimated to cost less than US$50,000 equivalent per contract may be procured under contracts based on Consultants' Qualifications in accordance with the provisions of paragraphs 3.1 and 3.7 of the Consultant Guidelines. Financial and technical audits estimated to cost less than US$75,000 equivalent may be procured under Least Cost Selection (LCS) in accordance with provisions of 3.1 and 3.6 of the Consultant Guidelines Consultant services meeting the requirements of section V of the Consultant Guidelines, may be selected under the provisions for the Selection of Individual Consultants (i.e. through the comparison of the curriculum vitae of at least 3 qualified individuals). No civil servants can be hired as consultants. Single source selection may be used exceptionally for: (i) training; (ii) consulting assignments provided by NGOs or other organizations to assist provinces, districts and community sub-projects estimated to cost less than US$10,000 equivalent per contract up to an aggregate of US$200,000, and (iii) Consultant assignment provided by Camerwa as procurement agent using the WHO pre-qualified list of pharmaceutical, may with the prior Association's agreement, be procured in accordance with paragraph 3.8 to 3.11 of the Consultant Guidelines. Short-lists for contracts estimated to cost less than US$100,000 equivalent may be comprised entirely of national consultants (in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines), provided that a sufficient number of qualified individuals or firms (at least three) are available at competitive costs. Training, workshops, conference attendance and study tours would be carried out on the basis of approved annual work programs that would identify the general framework of training or similar activities for the year, including the nature of training/study tours/workshops, number of participants, and cost estimates. - 67 - Table Al: Consultant Selection Arrangements (optional) (US$ million equivalent) r - , _. , ,,, . - ' '' Wrt Selection Method .. , Consultant Services ; 'Expenditure Category QCBs B SFB*> LCS .CO Other.' N.9F. Tot'l CowL',l A. Firms 2.02 0.00 0.00 0.28 0.20 0.14 0.00 2.64 (2.00) (0.00) (0.00) (0.27) (0.19) (0.13) (0.00) (2.59) B. Individuals 0.00 0.00 0.00 0.00 0.45 0.12 0.00 0.57 __________________ (0.00) (0.00) (0.00) (0.00) (0.44) (0.11) (0.00) (0.55) Total 2.02 0.00 0.00 0.28 0.65 0.26 0.00 3.21 (2.00) (0.00) (0.00) (0.27) (0.63) (0.24) (0.00) (3.14) Including contingencies Note: QCBS = Quality- and Cost-Based Selection QBS = Quality-based Selection SFB = Selection under a Fixed Budget LCS = Least-Cost Selection CO = Selection Based on Consultants' Qualifications Other = Selection of individual consultants (per Section V of Consultants Guidelines), Commercial Practices, etc. N.B.F. = Not Bank-financed Figures in parenthesis are the amounts to be financed by the Bank Grant. -68 - Prior review thresholds (Table B) Goods and civil works contracts estimated to cost US$100,000 equivalent or more would be subject to IDA prior review. In addition, the first three goods contracts and the first three civil works contracts below US$100,000 equivalent will be subject to IDA prior review. Contract under community based procurement estimated to cost US$75,000 equivalent or more will be subject to IDA prior review. In addition, the first five contracts under community-based procurement costing less than US$75,000 equivalent will be subject to IDA prior review. With regard to consultant services, all terms of reference and all single source selections regardless of contract cost, will be subject to IDA prior review. Contracts estimated to cost more than US$50,000 equivalent for individuals and more than US$100,000 equivalent for firms will besubject to IDA prior review procedures. All other goods, civil works and service contracts would be subject to post review by IDA during supervision missions and by auditors during the technical and financial audits. Procurement Supervision and technical audit During the first year of the project activities, a Procurement Specialist will supervise the Rwanda MAP every four months and thereafter, once every six months provided project performance is satisfactory. During these missions a selective post review of contracts awarded below the threshold levels described above will be conducted. The project activities would be subject to annual technical audits carried out separately from the financial audits. - 69 - Table B: Thresholds for Procurement Methods and Prior Review , , .,, , c*-~;~-Contract Value'-. Contracts Subject to Threshold Procurement 'Prior Review -. Expenditure'Category (US$ thousands)- Method '(US$ millions) 1. Works >500 ICB All <500 NCB All > 100 and the first 3 contracts < 100 <50 > Three quotations First 3 contracts (Post Review) 2. Goods >100 ICB All <100 NCB First 3 contracts <100 -< 10 Shopping None (Post review) 3. Services Firms >100 QCBS All <75 LCS Post Review Individuals ~<50 CQ Individuals >50 IC ( Section V of All (TOR, contract, CV) <50 Guidelines) Review of TORs only 4. Sub-Projects All values however project Community based All contract > 75 and the over 100 should be procurement first 5 subprojects costing exceptional less than 75 5. Training All values Post review apart from training abroad, annual training plans to be prior reviewed by IDA 6. Miscellaneous Total value of contracts subject to prior review: Overall Procurement Risk Assessment: High Frequency of procurement supervision missions proposed: One every 6 months (includes special procurement supervision for post-review/audits) Thresholds generally differ by country and project. Consult "Assessment of Agency's Capacity to Implement Procurement" and contact the Regional Procurement Adviser for guidance. - 70 - Annex 6(B) Financial Management and Disbursement Arrangements REPUBLIC OF RWANDA: Multi-Sectoral HIV/AIDS Project Financial Management 1. Summary of the Financial Management Assessment The Project Management Unit (PMU), being established under the Executive Secretariat of the CNLS, will be responsible for the day-to-day management of the project. The PMU will be independent and have full autonomy to make decisions on matters related to the project. The PMU will be responsible for managing the project accounts, ensuring that project expenditures are incurred in accordance with established procedures and maintaining adequate supporting documentation which will be made available for verification by IDA supervision missions and external auditors. It will handle all financial management coordination, including the preparation and submission of monthly withdrawal application requests, quarterly Financial Monitoring Reports (FMRs) and annual project accounts. In addition, it will also provide technical assistance on financial management procedures and Financial Management Reports to line ministries and other stakeholders benefiting from the project. Finally, the PMU will arrange for an independent internal auditor to ensure quality control. During the course of the pre-appraisal mission the World Bank Financial Management Specialist met with the CNLS financial team (i.e. Financial Director and Accountant) in the Directorate of Administration and Finance to review financial management capacities and discuss proposed arrangements for the project. The main conclusions and recommendations stemming from this assessment are summarized below: * Staffing; The Bank mission concluded that the CNLS team is adequately qualified and familiar with World Bank financial procedures. It was agreed that minimal core capacities would be established prior to negotiations by recruiting a Financial Management Specialist with other financial management/accounting staff to be recruited by effectiveness. * Project Financial Manual and Financial Monitoring Reports: The CNLS financial team is in the process of developing a Manual of Administrative, Financing and Accounting Procedures describing the accounting system & procedures, internal controls, chart of accounts, flow of funds from PMU to beneficiaries, external & internal auditing arrangements, and roles and responsibilities of the key staff responsible for project funds; and Financial Monitoring Reports (FMRs). The mission reviewed the state of advancement of these documents and provided comments. The Manual along with the FMRs were finalized during negotiations. * Terms of References: The term of references (TORs) for the recruitment of a Financial Management Specialist (Annex II) and an External Audit (Annex ID) were prepared and discussed with the financial team at the CNLS. It was agreed that the TORs for the Financial Management Specialist would be used to ensure recruitment of this specialist prior to negotiations and that the TORs for the external auditor would be finalized prior to negotiations. These measures were complied with by negotiations. * Flow offunds: The World Bank Financial Management Specialist reviewed the mechanisms for the flow of funds to the implementing agencies, namely the line ministries, NGOs and community based organizations. The flow of fund mechanism is described in the operational manual. * Line ministries and other public agencies: Line ministries and other public agencies that are ready to implement MAP activities (i.e. those with HIV/AIDS strategic plans and approved work plans) will - 71 - sign a formal Memorandum of Understanding (MoU) agreement with the CNLS. Funds will be made available from the PMU to MAP accounts in the line ministries in the form of initial advances covering approximately 90 days requirements with subsequent monthly replenishments. The subsequent replenishments will be done based on review and approval of activities implemented and funds utilized during the last month, a bank account reconciliation statement and a copy of the bank statement submitted to the PMU. * NGOs: This will follow an "on granting" mechanism where by the CNLS will select up to three on granting NGOs during the first year and gradually increase the number in subsequent years depending on performance. The amount for each "on granting" arrangement will be around US$150,000, of which 85% will be used for sub-grants up to US$15,000 each with 15% of funds allowed for administrative costs. The PMU will enter into contracts with NGOs selected and funds will be channeled to accounts opened for MAP activities. * Community Based Groups: MAP funds for HIV/AIDS interventions destined to community based groups will be channelled from the PMU to the Community Development Committees (CDCs) following the existing mechanisms and procedures that have been successfully piloted under the IDA-financed Community Reintegration and Development Project (CRDP). The CRDP is being implemented in 12 districts (covering 5 provinces) and is managed by the Ministry of Local Government. Based on the good performance of this project in terms of its capacity to support sub-projects designed and implemented by community groups and the financial management mechanisms to channel funds to communities the mission feels that this represents the best way to piggyback funds for HIV/AIDS interventions. During the pre-appraisal mission the Bank Financial Management Specialist assessed the financial capabilities of the first four line ministries that are considered 'ready' and will get funds during the first year of MAP implementation. The team also evaluated the capacities of the CRDP operation which has successfully channelled funds to community based groups. This review included: the Ministry of Defense, Ministry of Health, Ministry of Youth, Sports, and Culture and Ministry of Local Government and Social Affairs (MINALOC), and the Community Development Committees (CDCs) under IDA-funded Community Reintegration Development Project (CRDP). The Bank mission also assessed the financial management capacities of a sample of NGOs which are already implementing HIV/AIDS related activities (e.g. Rwanda Federation of Private Sector Associations, Biryogo Social and Medical Center, Christian Council of Rwanda) to get a sense of the level of capacities which prevail in this sector. The assessment revealed that, the above mentioned implementing agencies are capable of undertaking MAP activities and accounting and reporting on the use of funds. They have good accounting systems and financial management guidelines and controls that can be relied on. Each of these entities has qualified accounting staff able to manage the funds. With regard to the large NGOs to be selected for on-granting to smaller organizations, a more in depth financial management assessment will need to be done prior to contract signing. In addition, the overall country accountability issues were reviewed based on the July 2002 Country Portfolio Performance Review (CPPR) and the Financial Accountability Review completed September 2002. Key financial management risks faced by the country A. Issues arising from the CPPR: (i) Timely availability of counterpart funds The government has failed to fulfill its commritments as agreed during the CPPR to clear all the counterpart arrears for last FY. For example, the CRDP did not receive the last FY counterpart funds of RwF150,000,000. For this FY, the project has received only -72 - RwF40,000,000 (US$ 44,000 equivalent) out of RwF200,000,000 (US$444,000). (ii) Weakfinancial management capacity Project staff lack knowledge of the Bank financial management procedures and guidelines. (iii) Slow disbursements despite increased efforts by the Bank to strengthen implementation capacities. (iv) Late submission of project audit reports Two out of seven project audits were not submitted to IDA by their respective due dates. B. Issues arising from the Financial Accountability Review: (i) Weaknesses in the budgetary processing and monitoring system: government cash budget releases undertrine the MTEF prioritizing process, the budget monitoring system within the ministries is poor, and the budget control system is not decentralized to the lower levels but centralized in the Ministry of Finance and Economnic Planning. (ii) Weakness in the public sector accounting and reporting: There is not a set of consolidated public accounts, and there are no clear government financial procedures and guidelines being followed. The Local Government Financial Management and Accounting Procedures Manual needs to be updated to take into consideration the accounting system being developed. (iv) There are severe human capacity constrains and staff turnover problems. (v) Weak Internal Audit Unit. There are few Internal Auditors in the ministries who are not experienced and well trained. Major strengths observed in the review includes: (i) The autonomy given to the Office of Auditor General in carrying out its obligations as an independent auditor of govemment accounts for all public offices, local communities, and donor-funded projects. The high quality of the staff and of the audit reports are worthwhile highlighting. The Office of the Auditor General carries out external audits for all ministries on an annual basis. Accounts for FY1999, FY2000, and FY2001 have been completed and tabled to the General Assembly. (ii) The government has taken some initiatives to enhance financial management accountability at the central and local levels. This is through the proposed Public Act (a draft) and establishment of the National Tender Board. (iii) The government is in the process of strengthening public institutions in the country. For example, the capacity of the Institution for Public Finance is being strengthened to enable it to offer various courses in banking, insurance, accounting, auditing and to expand training of accounting professionals. (iv) Adequate financial management arrangements and controls are in place for the key implementing agencies assessed. To address these financial management risks the government has agreed to implement the following mitigation measures: * Put in place adequatefinancial management arrangements, including efficient flow of fund mechanisms, establishing two Special Accounts, organizing for external audits, elaborating a Manual of Administrative, Financial and Accounting Procedures and recruiting qualified financial management staff. * Make an initial advance deposit into the local account as part of the counterpart funds. * Provide periodic training during the life of the project on Bank procedures and guidelines (e.g. financial management, disbursement, project plahning, budgeting and monitoring & evaluation). In addtion, authorities have ageed to publish information on funds received in order to ensure full transparency. - 73 - Borrower compliance with audit covenants: There are no outstanding audits under IDA-funded projects. Based on the above assessment the overall financial management risk is rated as medium. 2. Audit Arrangements External Auditor The Project Management Unit will prepare consolidated annual financial statements for external auditing purposes. These will comprise of: (i) the Project Account (Source and Application of Funds by category), SOE schedule, Special Account Statement, Project Balance Sheet and notes on the financial statements. An independent private auditor, acceptable to IDA, will be appointed to carry out the audit of all project accounts. The annual financial statement audits will be carried out in accordance with IDA guidelines on project auditing and financial reporting, as outlined in The World Bank Financial Accounting Reporting and Auditing Handbook (FARAH). The audit shall be in accordance with the International Standards on Auditing promulgated by the International Federation of Accountants (IFAC). The audit report for the project will include separate opinions for the project financial statements, the Special Accounts, Statements of Expenditures (SOEs) and Audit Management Letter. The Borrower will submit to IDA audited financial statements and the audit report within six months following the end of their fiscal year. The Terms of Reference for the external audit were agreed upon with IDA and the selection process is now underway. During negotiations it was agreed that by March 31, 2003, the govermment will establish a short list, satisfactory to IDA, for the recruitment of the external independent auditor and by grant effectiveness the auditors will be appointed. Internal Auditor In addition to the normal internal checks and verifications that are carried out by internal units in various agencies, the internal auditing arrangements will be developed and carried out on quarterly/semi annually/randomly, as needs arise, by an independent internal auditor/consultant. The internal audit will focus mainly on the implementing agencies' adherence to their contractual obligations, including ensuring transparency and accountability in the use of grant proceeds at all levels. It will also involve a review of timeliness of funds and of proposed recommendations for improving financial arrangements. The internal audit activities will strengthen accountability and transparency, and ensure timely flow of funds to all project beneficiaries. A simple internal audit checklist will be developed and incorporated in the project financial manual. 3. Disbursement Arrangements Allocation of grant proceeds (Table C) The project is expected to be completed in five years (2003-2008. The completion date of the grant is April 30, 2008 with the grant closing on October 30, 2008. While operating under traditional disbursement procedures, all disbursement will be fully documented at the time of submission of withdrawal applications, except for expenditures made against statement of expenditures (SOEs). - 74 - Table C: Allocation of Grant Proceeds ..Expenditure Category . Amount In;US$miIIion - Financing Percentage 1. Civil Works 0.66 90.0 2. Goods 8.20 100.0 (a) Drugs & HIV/AIDS Commodities (b) Equipment and Vehicles 0.52 100.0 3. Consultants' services & audits 0.95 100.0 of foreign and 85.0 percent of local consultants 4. Training 2.04 100.0 5. Work Plans: Public Sector 4.63 90.0 6. Sub-Grants for Sub-Projects 9.55 100.0 7. Operating Costs 2.87 90.0 8. Unallocated 1.08 Total Project Costs 30.50 _ Total 30.50 _ Use of statements of expenditures (SOEs): Contracts not subject to IDA prior review will be reimbursed against certified SOEs. Thus SOEs will be used for paying of works and goods contracts costing US$100,000 equivalent or less, for contracts of services by firms costing US$100,000 equivalent and for services by individual consultants costing less than US$50,000 equivalent; as well as for all training, operating costs and sub-projects under the civil society component. A simplified format will be used for SOEs in which expenditures are summarized by category. The Project Management Unit would retain the documentation for withdrawal under SOEs for review by IDA during supervision missions and for annual audits. All disbursements are subject to the conditions of the Grant Agreement and to the procedures defined in the disbursement letter. Special account: To ensure timely and reliable flow of funds to all stakeholders, the Project Management Unit will open two Dollar Special Accounts (SA) (i.e. Special Account A and B), and one local currency account in the Central Bank of Rwanda (Banque Nationale du Rwanda). IDA funds will be deposited into these two special dollar accounts. The accounts will be replenished on the basis of SOEs or specific withdrawal applications to be submitted to IDA on a monthly basis. The two special accounts will be used, as follows: (i) Account A will be used,to fund the activities under the civil society component, including NGO and community sub-projects. (ii) Account B will be used to fund support of line ministries and other public sector organizations' HIV/AIDS work plans; operational support, coordination and capacity building activities for the CNLS, CPLS and CDLS; and support to establish and maintain the Project Management Unit. Having two dollar special accounts will ensure timely availability of funds for both the civil society organizations and the public sector agencies. It will also help to prevent potential problems with components funded from one SA from affecting those funded from the other, and thereby avoid delays in - 75 - replenishments. The administration of the Special Accounts and the Project Account, including preparation of withdrawal applications and replenishment of the accounts, will be the responsibility of the Project Management Unit. The Special Account replenishment applications will include reconciled bank statements as well as other appropriate supporting documents. - The maximum amount or authorized allocation will be US$650,000 equivalent for special account A (grants) with an initial deposit of $325,000 and a benchmark of SDR 750,000. The authorized allocation for Special Account B (everything else) would be $1,350,000 with an initial deposit of $675,000 and a benchmark amount of SDR 1,500,000. Proposed Flow of Funds For an agency to qualify for MAP funding, it must: (a) provide a work plan prepared by its respective HIV/AIDS committee/commission which includes details of the activities to be funded, estimated costs, implementation arrangements and agreed performance indicators, and arrangements for accounting and reporting of funds; (b) have its MAP activities approved by the CNLS; (c) sign a Memorandum of Understanding (MoU) between the respective public sector implementing agency and the CNLS and a formal contract between the respective NGO and the CNLS; and (d) open a local project account. Each implementing agency that is ready to implement MAP activities (i.e. those with approved HIV/AIDS work plans and sub-projects) will operate separate bank accounts for MAP activities. Funds will be made available to these agencies in the form of initial advances to these dedicated bank accounts, covering approximately 90 day requirements and subsequently funds would be made available though monthly replenishments. The subsequent replenishments will be done based on review and approval of activities implemented and funds utilized during the past month, a bank account reconciliation statement, and a copy of the bank statement submitted to the PMU. * Line Ministries, CNLS Secretariat, and PMU: Following approval of work plans and budgets the PMU will transfer funds directly to the respective local accounts of the respective implementing agency. In case of line ministries, upon receipt of funds to the dedicated MAP local account, funds will be channelled within the ministry to the various sector units at the national, provincial, district and local levels through existing government accounting procedures and systems in place. The release of funds will be based on the consolidated annual work plans and budgets of the respective line ministry. Each implementing agency will provide administrative and technical support to their MAP implementing sector units, including relevant guidelines on how the MAP funds should be accounted for (e.g. recording & reporting formats), and routine monitoring and evaluation procedures. * Civil Society Organizations: The PMU will transfer approved MAP funds directly to the established MAP local bank accounts of the respective NGO. Disbursements to these accounts will be made according to the provisions of the relevant contract between the respective agency and the CNLS. In case of funds chanelled to community groups through the CDCs, the financial arrangements, including flow of fund mechanisms, will follow the already existing procedures under the IDA-funded CRDP operation. Accounting and Financial Arrangements A simple financial management system, as stipulated in the Manual of Administrative, -76 - Financial and Accounting procedures, is being developed for the project, and will be used to guide financial arrangements for the HILV/AIDS activities. The financial management framework will ensure appropriate safeguards are in place in the PMU and in all implementing agencies. To ensure transparency and accountability at all levels, the following key activities will be carried out: (i) dissemination of information on the amount of funding received and spent and discussion of technical progress; and (ii) internal audits of fund utilization and activities completed. The internal audit report will be submitted to the respective line ministries, CNLS, CPLS, and CDLS. The financial approvals will be based on a performance based contract approach for financing annual programs as indicated in the Operational Manual. The project accounts will be maintained in accordance with the borrower's financial regulations, and internationally accepted accounting principles as well as the Manual of Admninistrative, Financial and Accounting procedures. Each implementing agency will retain all original supporting documentation (such as receipts, invoices, etc) for subsequent verification by internal and external auditors and World Bank staff during supervision missions. Financial Monitoring Reports (FMRs) The Project Management Unit will need to demonstrate capacity to prepare regular Financial Management Reports (FMRs), which are needed for monitoring the financial aspects of project implementation. The current CNLS accountant has already attended training on FMRs which was conducted.by a World Bank Financial Management Specialist and is familiar with FMR guidelines. A draft of the FMRs was prepared during the pre-appraisal mission with the final version agreed upon during negotiations and attached to the minutes of negotiations dated March 1, 2003. The PMU will prepare and submit quarterly consolidated FMRs to the CNLS, MOF, and IDA within 45 days of the end of the reporting period. FMRs will be used as financial reporting inputs into the overall project monitoring progress report. The FMRs would include: financial reports, physical progress reports, and procurement reports. * Financial reports will show: (i) quarterly and cumulative cash inflows and outflows, and (ii) expenditures reported according to project activities, and according to procurement/disbursement categories. * Physical progress reports will include information on the state of implementation of project activities, linking these to the financial reports. Indicators for monitoring technical progress would be selected during project preparation, and included in the Operational Manual. * The procurement report will include: (i) the status of procurement of goods, works, and services, (ii) a comparison of procurement performance against the procurement plan agreed upon with the Bank during negotiations or in subsequent reviews, and (iii) identification of specific problems and recommended solutions. Computerization of accounting system In order to assist the PMU in maintaining an acceptable accounting and reporting system, and to ensure that an adequate integrated financial monitoring reporting of the project activities is in place, a computerized accounting software will be developed during implementation of the project. Supervision: With several implementation agencies involved (e.g. line ministries, NGOs, local authorities and communities), monitoring of financial transactions, including field visits, will be crucial and - 77 - recruitment of additional staff may be necessary as activities expand. Independent internal auditing arrangements will be carried out on quarterly/semi annually/randomly, as needs arise. This is to ensure transparency and accountability in the utilization of funds at all level and to assure that contractual obligations are respected by all implementing agencies. In addition, close supervision and timely resolution of problems especially with regard to coordination and flow of funds to beneficiaries is equally important. During implementation IDA will ensure that the project maintains satisfactory financial management arrangements through SOE and quarterly FMR reviews to be done by an IDA Financial Management Specialist. Interim Assessment As discussed with Rwandan authorities during the pre-appraisal mission, the financial management arrangements described above will be evaluated at the end of the first 18 months of implementation. This interim assessment will determine the adequacy of the overall financial management arrangements under the Rwanda MAP, and the need to take remedial action. Annex 11 includes a discussion of the types of interim indicators to be used for assessing the effectiveness of the financial management arrangements. -78 - Annex 7: Project Processing Schedule REPUBLIC OF RWANDA: Multi-Sectoral HIV/AIDS Project Project Schedule - - - Planned - Actual- Time taken to prepare the project (months) 12 24 First Bank mission (identification) 04/16/2001 04/16/2001 Appraisal mission departure 12/11/2002 01/13/2003 Negotiations 01/06/2003 02/28/2003 Planned Date of Effectiveness 04/15/2003 07/15/2003 Prepared by: The preparation of the project was initiated under the leadership of Malonga Miatudila (Task Team Leader). An identification mission was carried out in April 2001 to hold initial discussions with Rwandan authorities about the objectives and content of the proposed operation. Preparation work continued through December 2001 when a high-level Rwandan delegation visited Bank headquarters. With assistance from a PHRD grant, awarded by the Japanese government, authorities were able to prepare an initial project proposal which served as the basis for discussions with the Bank team. These discussions experienced some difficulties and the project preparation process came to a temporary halt. The preparation process was relaunched with a May 2002 preparation mission. The Bank team which worked on the project is listed below. Significant contributions were by the national multi-sector team under the leadership of the late Dr. Philippe Bandora (Executive Secretary, CNLS) and a core group of Rwandan experts (Dr. Ntaganira, Mr. Davukiye, Mr. Gasana) working with the commissioners of the national program. The grant was negotiated by a delegation headed by Dr. Innocent Nyaruhirira, Minister of State in Charge of HIV/AIDS and other Infectious Diseases, Ministry of Health and comprising of: H.E. Dr. Richard Sezibera, Ambassador of Rwanda, Washington, D.C., Dr. Agnes Binagwaho, Executive Secretary, CNLS, Dr. Chantal Kabagabo, Director of Health, Presidency, Dr. Sam Kanyarukiga, Director General, CEPEX, Dr. Thomas Karengera, MAP Project Coordinator, Mr. Alphonse Gasana, Director of Administration and Finance, CNLS, and Mr. Christian Rugerinkusi, Lawyer, CEPEX. Preparation assistance: A Japanese grant for US$683.900 (TF026734) was received for project preparation. The Bank-managed grant was instrumental in funding a number of priority activities: (i) development of a multi-sectoral appraoch to control HIV/AIDS through the design of an operation consisting of multi-sectoral activities, compilation of information on multi-sectoral activities carried out by different stakeholders, and institutional assessments of key stakeholders; (ii) design of efficient implementation and evaluation mechanisms, including the preparation of an operation manual, implementation and work plans, procurement and financial management arrangements, and costing of project activities; (iii) development of a waste management plan; (iv) assessment of needs of young children impacted by the HIV/AIDS epidemic; (v) evaluation of the impact of HIV/AIDS on the health sector and on households; (vi) analysis of the links between reproductive health and HIV/AIDS programs; and (vii) assessment of feasibility of introducing an antiretroviral therapy pilot component under the project. The grant was instrumental in assisting Rwandan authorities to carry out broad based consultations and to prepare an initial project proposal. All activities are to be completed by the closing date of March 20, 2003 - 79 - Bank staff who worked on the project Included: Name Speciality Miriam Schneidman Senior Health Specialist, Task Team Leader Pamphile Kantabaze Senior Operations Officer, Deputy TTL Sheila Dutta Health Specialist Toni Kayonga Operations Officer Prosper Nindorera Procurement Specialist Mercy Mataro Sabai Senior Financial Management Specialist Christy Hansen TB Specialist Mark Blackden Lead Economist Francesco Tornieri Gender Specialist Shimwaayi Muntemba Senior Social Scientist Michael Fowler Disbursement Specialist Hassane Cisse Counsel Abdul Haji Senior Financial Management Specialist Serigne Omar Fye Environment Specialist Nathalie Lopez-Diouf Program Assistant Leoncie Niyonahabonye Program Assistant Antoinette Kamanzi Program Assistant Anne Anglio Program Assistant Non-Bank Staff: Pia Schneider Economist Souleyman Kanon Public Health Specialist Kristine Storholt Gender/Social Sector Specialist Pascal Dooh-Bill Institutional Development Specialist Jerome Chevallier Development Specialist Frode Davanger Operational Specialist Anne Marie Bodo Pharmaceutical Specialist Peer Reviewers: o Christopher Walker, Lead Specialist, Health Nutrition and Population Quality, HD Network o Albertus Voetberg, Lead Health Specialist, AFTHl - 80 - Annex 8: Documents in the Project File* REPUBLIC OF RWANDA: Multi-Sectoral HIV/AIDS Project A. Project Implementation Plan The Project Implementation Plan for the first year of the project was prepared in June 2002. B. Bank Staff Assessments N/A C. Other The Rwanda National HIV/STD/AIDS Strategic Plan Framework for the MTPlII Period 1998 to 2001. Republique Rwandaise, Ministere de la Sante - PNLS, October 1998 Bouda O., Twiyubahe F., Gatete, F. Plan National Multisectoriel de Lutte Contre le VIHISIDA 2002-2006. Republique Rwandaise, CNLS, Mai 2002 Cadre Strategique National de Lutte contre le VIH/SIDA 2002-2006. Republique Rwandaise, CNLS, Mai 2002-07-02 Calves AR., 1998 Rwanda Sexual Behavior and Condom Use Survey. First Report Patel K., PSI/Rwanda Health Animator Analysis Enquete sur les connaissances, attitudes et pratiques aupres des jeunes des m6nages de la ville de Butare et des communes avoisinantes. Rwanda 2001 La Communication Interpersonnelle Aupres des Fenmmes Libres - PSI Rwanda Possible areas of intervention PSI Behavior Change Model Evaluation de Base de la Prise en Charge des IST dans la Region Sanitaire de Kibuye - FHIIIMPACT. Fevrier 2001 Evaluation pour l'annee 2001 de la prise en charge des Infections Sexuellement transmissibles (IST) dans les provinces de Byumba, Gitararna, Kibungo, Kigali Ngali et la Mairie de la Ville de Kigali - FHBIIMPACT. Mars 2002-07-02 Rapport Annuel 2001 - Republique Rwandaise. Mars 2002-07-02 Implementing AII)S Prevention and Care (Impact) Project - FCO#: 82563 Serosurveillance de l'Infection a VIH Chez les Femmes Enceintes Frequentant les Services de Consultation Pr6natale - Ministere de la Sante - TRAC, 2002 Donn6es Brutes CDV - H6pitaux de District de Kabgayi, Rwamagana et Ruli - Periode : Aout 2000 a Octobre 2001 - FHI/IMPACT. Decembre 2001 - 81 - Rapport du Seminaire de Restitution des Resultats de l'Etude sur la Sante de la Reproduction et les Droits de la Femme au Rwanda. SWAA - Rwanda 1IHIUMURE > - Decembre 2001 Etude sur la Sante de la Reproduction et les Droits de la Femme Rwandaise - SWAA - Rwanda < IHUMURE >> - Decembre 2001 Child Headed Households in Rwanda - A qualitative Needs Assessment - World Vision Rwanda & World Vision UK, February 1998 Action Plan - National Women Council - NA.WO.CO Living with HIV/AIDS in Rwanda Experiences in Creating a Conducive Environment for Girls in School - FAWE Girl's School - Rwanda The National Students Festival, July 7th-9th 2001 - Forum for African Women Educationalists (FAWE) Rwanda Chapter The FAWE Rwanda Three-Year Work Program (2002-2004) - Draft - Forum for African Women Educationalists (FAWE) Rwanda Chapter Rapport Annuel des Activites du Projet de Stabilisation de l'Education de la Fille au Rwanda - Phase I and m - Forum for African Women Educationalists (FAWE) Rwanda Chapter Women's effort to fight HIV/AIDS - SWAA - Rwanda ff IHUMURE >> Institutional Support to SWAAR Mukangira J., Bovard L. - Counseling Report for 2001 - Rwanda Christian Counseling and Training Center, RCCTC, November 2001 Recherche de base sur la SRA au Rwanda - PSI Rwanda, 13 Decembre 2001 Centre Dushishoze Activites / besoins et resources dans tous les districts de Butare - PSI Rwanda The Support to the International Partnership Against AIDS in Africa - SIPAA Rwanda, May 2002 Dick A., Ho D., Long M. - Mobilizing for Life A comprehensive program of Rwandan churches to reduce HIV/AIDS among youth and to care for youth affected by HIIV/AIDS Invitation du Prefet de la Province de Gisenyi - CNLS, Aout 2001 Terms of Reference of the CCM Rwanda Rwanda Malaria CCP Presented to the Global Fund - Rwanda CCM, March 10, 2002 - 82 - Annex I - Budget Information. Rapport de la Reunion sur le Global Fund - Janvier 2002 Compte Rendu de la Conf6rence d'information sur le CCM H6tel Novotel - 19 f6vrier 2002 Compte Rendu de la rdunion du CCM Rwanda - 25 fevrier 2002 HIV/AID-S/TB Proposal to the Global Fund - Rwanda CCM Common Country Assessment Rwanda HIV AIDS 1999-2000 - CCA Paper 9 Rwanda and HIV/AIDS - USAID & IMPACT, April 1999 Common Country Assessment Rwanda Gender 1999-2000 - CCA Paper 10 Common Country Assessment Rwanda Child Protection 1999-2000 - CCA Paper 11 HIV/AIDS and Gender an awareness raising folder - Norwegian Working Group on HIV/AIDs and Gender Guidelines for Studies of the Social and Economic Impact of HIV/AIDS - UNAIDS, September 2000 Gender and HIV/AIDS Taking stock of research and programmes - UNAIDS, March 1999 Carte Administrative du Rwanda - MINITRACO et CGIS-UNR, 2001 Dilemmas Facing Mothers in the Time of AIDS Handverkeren kurs- og konferansesewnter, Oslo Seminar Report - November 19, 2001 Indatwa z'ejo Magazine - No 002 Mutarama 2002 *Including electronic files - 83 - Annex 9: Statement of Loans and Credits RWANDA: Multi-Sectoral HIV/AIDS Project 1 1-Mar-2003 Difference between expected and actuial Original Amount In US$ Millions disbursements Project ID FY Purpose IBRD IDA Cancel. Undisb. Orig Frm ReVd P066385 2003 RWANDA- INSTITUTIONAL REFORM CREDIT 0.00 85.00 0.00 41.54 -46.05 0.00 P075129 2002 RW:Desobilization and Reintegration 0.00 25.00 0.00 22.48 0.79 0.00 P064965 2001 Rwanda-Rural Sector Support Proect 0.00 48.00 000 47.34 1l.99 0.00 P065788 2001 Regional Trade Fec. Proj. - Rwanda 0.00 7.50 0.00 5.73 1.29 0.00 P057295 2001 Cornpetitiveness & Enterprise Development 0.00 40.80 0.00 40.95 15.68 0.00 P058038 2000 RW: AGRIC. & RURAL MARKET DEVELOPiHT. 0.00 5.00 0.00 2.38 2.31 0.00 P045091 2000 Hunan Resource Dev. 0.00 35.00 0.00 29.04 15.684 0.00 P045182 2000 RW-Rural Water Supply & Sanitation Proje 0.00 20.00 0.00 17.99 0.96 0.00 P051931 1999 Conreunity Reintegration (CRDP) 0.00 5.00 0.00 0.38 0.54 0.00 Total: 0.00 271.30 0.00 207.83 7.13 0.00 RWANDA STATEMENT OF IFC's Held and Disbursed Portfolio Jun 30 - 2002 In Millions US Dollars Comniitted Disbursed I1FC IFC FY Approval Company Loan Equity Quasi Partic Loan Equity Quasi Partic 2001 AEF Dreamland 0.80 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Total Portfolio: 0.80 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Approvals Pending Commitment FY Approval Company Loan Equity Quasi Partic Total Pending Commitment: 0.00 0.00 0.00 0.00 -84 - Annex 10: Country at a Glance REPUBLIC OF RWANDA: Multi-Sectoral HIV/AIDS Project Sub- POVERTY and SOCIAL Saharan Low- Rwanda Africa Income Development dlamond' 2001 Populatlon, mid-year (millions) 8.7 874 2,511 Life expectancy GNI per capita (Atlas method, USS) 220 470 430 GNI (Atlas method, USS billions) 1.8 317 1,069 Average annual growth, 1995-01 Population ()5.2 2.5 1.9 Labor force (%) 5.5 2.6 2.3 GNI Gross per ---- primary Most recant estimate (latest year avallable, 1995-01) capita ., enrollment Poverty (% of population below national poverty line) 60 Urban population (% of total population) 10 32 31 Ute expectancy at birth (years) 49 47 59 Infant mortality (per 1,000 live births) 107 91 76 Child malnutriton (% of children under 5) 29 Access to Improved water souroe Access to an Improved water source (% of populafion) .. 55 76 Illiteracy (% of population age 15+) 31 37 37 Gross primary enrollment (% of school-age population) 100 78 96 Rwanda Male 85 103 Low-income group Female 72 88 KEY ECONOMIC RATIOS and LONG-TERM TRENDS 1981 i991 2000 2001 Economic ratlos GDP (US$ billions) 1.3 1.9 1.8 1.7 Gross domestic investment/GDP 13.3 14.0 17.5 18.4 Exports of goods and services/GDP 9.8 7.3 8.3 9.3 Trade Gross domestic savingstGDP 1.4 3.3 1.4 1.9 Gross national savings/GDP 9.8 12.3 12.5 11.9 Current account balance/GDP -5.1 -1.7 -5.0 -65 Domestc ' Interest payments/GDP 0.2 0.3 12.8 12.2 Investment Total debt/GDP 14.9 42.4 72.1 77 3 savings Total debt service/exports 4.7 16.0 28.1 24.9 Present value of debVGDP 12.1 14.0 Present value of debt/exports 178.4 180.2 Indebtedness 1981-91 1991-01 2000 2001 2001-05 (average annual growth) GDP 1.6 1.9 6.0 6.7 6,4 Rwanda GDPpercapita -1.3 -0.5 3.5 4.1 3.8 Low-income group Exports of goods and services 2.3 1.5 9.4 39.9 1.8 STRUCTURE of the ECONOMY 1981 1991 2000 2001 Growth of Investment and GDP f%) (% of GDP) 4s Agriculture 43.5 33.0 41.4 40. Industry 22.2 21.5 20.5 216 so Manufacturing 16.8 16.6 9.7 9.8 Services 34.3 45.5 38.1 37.9 0 _a Private consumption 78.6 84.7 88.0 86.4 aio General govemment consumption 20.0 12.1 10.5 11.7 GDI e-GDP Imports of goods and services 21.8 18.1 24.4 25.8 1981-91 1991-01 2000 2001 Growth of exports and imports (%) (average annual growth) Agriculture 0.4 4.2 9.1 8.3 so Industry 0.9 -0.2 3.4 7.6 o Manufacturing 12 -1.7 -4.1 9.5 at099 Services 4.2 2.1 3.6 4.4 so Private consumption 1.7 1.9 4.6 2.0 s100 General govemment consumption 4.7 -0.8 1.1 18.2 so.1 Gross domestic investment 0.2 4.9 -15.1 3.0 -Expons -Imports Imports of goods and services 3.2 -11.4 4.0 Note: 2001 data are preliirrnary estimates. * The diaronds show four key indicators In tihe country (in bold) compared with its income-group average It data are missing, the diamond will be incomplete - 85 - Rwanda PRICES and GOVERNMENT FINANCE 1981 1991 2000 200i In(fation (%) Domesttc prices 0 (% change) Consumer prices 6.5 19.6 3.9 3.4 40 Implicit GDP deflator 7.7 15.0 3.2 0.2 20 Government finance (% of GDP, Includes current grants) 9 s 97 ss es o 0 Current revenue 12.2 15.t 18.7 19.8 2C - Current budget balance 1.2 -1.1 6.1 5.6 - GOPdeflator CPI Overall surplus/deficit -8.2 0.1 -1.1 TRADE fUSS millions) 1981 1991 2000 2001 Export and tmpon levels (USS mill.) Total exports flob) 113 96 90 93 4C Coffee 58 23 19 Tea 22 24 23 a* Manufactures 2 42 48 Total imports (cif) 302 328 340 2X Food 35 47 52 o* Fuel and energy 39 94 73 Capital goods 54 53 51 a 91 95 97 go 69 Do 01 Exportpriceindex(1995=100) 71 107 108 Importpriceindex(1995=100) 89 105 108 DExports Inrrports Termssoftrade(1995=100) 79 102 100 BALANCE of PAYMENTS (USS millions) 1981 1991 2C00 2001 Current account balance to GDP (%) Exports of goods and services 151 140 150 159 o Imports of goods and services 329 345 441 440 l Resource balance -178 -205 -291 -281 Net income 9 -11 -15 -20 Net current transfers 103 183 217 191 Current account balance -67 -33 -90 -110 Financing items (net) 48 99 100 121 Changes in net reserves 21 48 -10 -11 Memo: Reserves including gold (USS millionsj 173 110 191 212 Conversion rate (DEC, local/US$) 92.8 125.1 390.0 443.0 EXTERNAL DEBT and RESOURCE FLOWS 1981 1991 2000 2001 (US$ millions) Composition of 2001 debt (USS milL) Total debt outstanding and disbursed 197 810 1.305 1,316 IBRD 0 0 0 0 F IDA 65 390 692 713 E: 146 Total debt service 8 23 42 40 IBRD 0 0 0 0 IDA 1 4 11 14 Composition ot net resource flows Official grants 287 234 Official creditors 25 78 32 51 713 Private creditors 0 -1 4 13 Foreign direct investment 8 4 8 4 Portfolio eLquity c 84 World Bank program Commitments 14 147 77 96 A - IBRD E - ilateral Disbursements 7 48 37 53 B - IDA D - Other rnultitateral F - Private Principal repayments 0 2 6 8 C - IMF G - Sort-ternm Net flows 7 47 31 45 Interest payments 1 2 5 5 Net transfers 7 44 26 40 AI I JY 1 WuZ -86 - Additional Annex 111:Monitoring and Evaluation REPUBLIC OF RWANDA: Multi-Sectoral HIV/AIDS Project Introduction The National HIV/AIDS Strategic Framework of Rwanda recognizes that strong and flexible M&E systems are critical to the development of an effective response. This perspective is congruent with that of the MAP program which emphasizes the importance of developing and strengthening systems to generate early and regular information on program outputs, impact, as well as epidemic trends. It is viewed that monitoring serves largely as a program management tool, whereas evaluation enables the routine abstraction of lessons learned and of means in which program implementation could be improved. The government aims to put in place a comprehensive monitoring and evaluation which will include surveillance, epidemiologic research, financial management, and project monitoring. National Efforts As part of the implementation of the Global Fund-financed program, the Ministry of Health (TRAC) will be monitoring HIV/AIDS activities at three levels: (i) health center level, (ii) health district level, and the (iii) central or national level. These efforts are still largely in their planning phase, but provide important guidance regarding future directions in monitoring and evaluation. As per the protocol developed by the multi-partner Country Coordinating Mechanism (CCM) for the Global Fund, health centers will use standardized MOH forms to collect data on clients attending the integrated VCT service (VCT, STI and 01 treatment, and PMTCT) and will compile monthly reports with basic information, such as sex and age, on clients attending these services. Health centers will provide this report tQ health districts, in addition to client intake forms that collect more extensive data on client characteristics and service utilization. At the health district level, detailed client data will be computerized and reviewed in parallel with the monthly reports provided by health centers. The health districts will convene monthly feedback meetings (and supervision visits) with involved health centers to review reports and discuss constraints and possible solutions. At the central/national level, TRAC will be responsible for conducting quarterly monitoring visits to districts and health centers to monitor the implementation of integrated VCT activities and determine additional technical assistance needs. The National TB Program (PNLT) will provide the same level of monitoring support to TB activities at the health centers. In terms of national program evaluation, the MOH plans a number of different types of research and studies, including: * Evaluation of STI and 01 Case Management A baseline evaluation of STI and 01 case management followed by annual evaluations to determine the percentage of providers who are following national guidelines and to-inform refresher training programs. Patients records and health center-registries will be used to monitor and evaluate if patients have been correctly treated, and counseled on the importance of being tested for HIV. For example, antenatal and laboratory records will be used to monitor if all pregnant women have been tested for syphilis and if those who were found to be positive have been treated for syphilis. For syndromic case management of other STIs and treatment of Ols, registries will be reviewed to ensure that patients were provided with the correct drugs. * Home-Based Care Evaluation A baseline evaluation conducted by the national PLWHA association (ANSP+) to better understand current practices in home-based care in order to replicate promising approaches and determine priority areas for a national home-based care training guide. - 87 - * Client Satisfaction Surveys The Rwanda National University will implement client satisfaction surveys at a sampling of the health centers providing integrated VCT twice each year. In addition, focus group discussions will be run with select target groups, such as youth, to deternine how services can be strengthened to better meet their needs. * Quality Control The National Laboratory (TRAC) will be responsible for ensuring the quality of testing related to HIV and STDs. Ten percent of all samples from health centers offering integrated VCT services will be sent to the National Laboratory for quality control. This will enable routine evaluation of quality assurance in testing for HtV infection and STIs. National Laboratory staff will also engage in random site visits to obtain qualitative data on the overall quality of testing services Surveillance The Government of Rwanda recognizes that reliable and timely surveillance data are essential to the development and evaluation of HIV/AIDS prevention programs and also for the prioritization of resources according to population vulnerability to infection. Since 1997, the Rwandan approach to surveillance has focused on 10 sentinel sites, most of which are antenatal clinics. It is recognized that a more complete epidemniologic profile is needed, in terms of both sentinel populations and population-based seroprevalence. Improved integration of surveillance systems for STIs, TB, and HIV are also needed in order to better understand the overall dynamics of the epidemic and design appropriate remedial measures. The Rwandan National Strategic Framework intends to strengthen the capacity of national surveillance by improving the representativeness and quality of HiV surveillance data, increasing the usefulness and timeliness of surveillance data and its analysis, improving system maintenance, and providing adequate support to requisite linkages to behavioral surveillance. Under the national program, biologic and behavioral surveillance will be coordinated by the Directorate of Epidemiology and Hygiene within the Ministry of Health, in collaboration with the TRAC, CDCs, and other technical partners. The Directorate of Epidemiology has proposed the following measures to accomplish this core responsibility: * Carrying out a population-based serosurveillance survey Conduct of a large-scale population-based serosurveillance survey to better estimate levels and patterns of HIVJAIDS infection. Proposed activities under this survey include technical assistance in the development and piloting of the survey questionnaire, as well as in sampling methodology and survey logistics, support in the analysis and reporting of survey data, and provision of requisite training, personnel, equipment, and supplies. * Strengthening Sentinel Surveillance Comprehensive review of the current HIV sentinel surveillance system and the development of recommendations for the inclusion of additional sentinel groups and/or sites (e.g. STI clients, TB patients, "imidugudu" residents, rural areas with few HIV/AIDS-related programs). This review would also be used to suggest specials studies in support of evidence-based decision-making (e.g. to better understand epidemic dynamics in displaced populations); provide technical support to the evaluation of data collection forms, population sampling methods, and laboratory logistics; develop systems integrating biological and behavioral surveillance ("second generation surveillance"); support for technical and program management training, data management, and establishment of supervision guidelines and mechanisms; and improve timeliness of data reporting and dissemination and subsequent use in program planning. -88 - Program Monitoring The M&E system for the Rwanda MAP will primarily build on existing efforts to strengthen national systems, as guided by the National Technical Group on Monitoring and Evaluation and the Sub-Commission coordinating these activities within the CNLS, and by technical evaluations carried out by the .USAID-funded MEASURE/Evaluation Project. As can be seen from the figure below, the goal is to ensure sound technical and financial monitoring of project activities while tapping and/or supporting other national program efforts (i.e. periodic surveys, studies, evaluations). Moreover, given the 'learn by doing' aspect of the MAP, a major emphasis would be given to building knowledge management capacity with a feedback mechanisms to all stakeholders. __~~~~~~~~~~~~~~~K PI The MEASURE team has been working closely with the CNLS, TRAC, and other key partners in developing a multisectoral M&E strategy. The initial focus has been on the selection of an appropriate set of indicators and targets, which have been discussed and agreed upon with key stakeholders. The institutional assessment of monitoring and evaluation capacities is to be carried out subsequently, with a view to identifying financial requirements for strengthening these capacities. The Bank anticipates working in collaboration with the MEASURE team to identify priority areas for financing in support of the national monitoring and evaluation plan, as well as in the provision of technical support. The project will support, as necessary, activities to strengthen the monitoring and evaluation of the program. What is the evaluation process that is being used? The process of effectiveness evaluation that is being used in this project involves the following key steps: * Selecting appropriate indicators that correspond to program goals and objectives. * Setting targets for changes that are expected as a result of the proposed interventions. * Determining best methods for data collection and analysis. - 89 - o Assessing national capabilities in monitoring and evaluation. O Carrying out a stakeholder workshop to develop a detailed monitoring and evaluation plan, including roles, responsibilities, and time lines. What type of indicators would be monitored as part of the project management, monitoring and evaluation component? Within the five-year duration of this project it would be generally difficult to measure changes in HIV prevalence rates. The main focus would thus be on output, process and outcome measures, as presented in detail in Annex 1 and as summarized below: o Output indicators to measure changes in knowledge of HIV/AIDS prevention and transmission, and increases in the availability, uptake, and quality of range of FHV/AIDS-related services and activities. O Process indicators to provide an understanding on the level of efficiency and the scale of implementation of HlV/AIDS work plans and sub-projects. O Outcome indicators to assess effectiveness of preventive interventions would focus on changes in sexual behavior and increases in condom utilization that would ultimately lead to a reduction in IRV infection rates. Outcome measures to assess effectiveness of health service delivery, and care and support services would measure changes in percent of clients who are appropriately diagnosed and treated according to national guidelines and also changes in reported discrimination and stigmatization. What type of studies and surveys would be carried out? During the preparation of the Rwanda MAP, a Japanese-funded grant was used to support a number of key activities, including: (i) an evaluation of the impact of HIV/AIDS on the health sector and on households, with a view to identifying measures to mitigate the negative impacts; (ii) an assessment of the needs of vulnerable children who have been adversely affected by the epidemic and who are still suffering from the after effects of the trauma of the war and genocide; such information will assist organizations to design appropriate interventions targeted to these children; and (iii) an assessment of the feasibility of supporting a pilot ARV therapy component which is being carried out by the CDC (Atlanta). As indicated in the project logical framework, a large part of the data for the monitoring and evaluation system would come from the next Demographic and Health Survey, periodic Behavioral Surveillance Surveys and MOH records. These sources of data are collected in a regular fashion, enabling a longitudinal perspective on outcomes of interest. USAID and the CDC will likely be the major sources of financial support for the second round (2002/03) of the behavioral surveillance survey (BSS) planned for youth. In 2004, funds from the Global Fund are expected to support TRAC in ensuring that the third round of BSS is conducted for this group in an attempt to monitor trends in knowledge, attitudes and behaviors among young people,. Given the critical nature of these surveys as program monitoring tools, in discussions with the Government and partner agencies, the project team indicated willing to co-finance the next round of DHS and BSS surveys if further resources are required. Data from the DHS/BSS will be complemented with qualitative research such as Beneficiary Assessments, Focus Group discussions and other participatory approaches to increase understanding of impact at community-level and also enhance. local ownership and accountability. Process indicators will be monitored through: (i) quarterly technical and financial progress reports submitted by organizations participating in the implementation of the project; and (ii) annual reviews that would be organized by the CNLS. How would technical andfinancial monitoring be carried out? A simple management information system (MIS) will be put in place at the central level to monitor both the technical and financial aspects of project implementation. The MIS would be based on quarterly project reports to be submitted by all implementing organizations. It would monitor project-specific aspects such as: - Expenditures by level (i.e. by central, provincial, district, and community levels) - 90 - - Number of beneficiaries reached by level - Number of projects financed - Types of activities funded - Time lapses between submission and approval of plans and between approval and funding/disbursement at each level. Who would be responsible for monitoring and evaluation? All implementing agencies (CNLS structures, line ministries, NGOs, communities) will be responsible for monitoring and evaluation of their respective work plans, grants, and sub-projects. The CNLS will have the overall responsibility for monitoring and supervising activities of national, provincial and NGO authorities. The CNLS will also compile and consolidate technical and financial information on a quarterly basis. The CNLS M&E unit will coordinate and collaborate with the central statistics office, TRAC/MOH, UN agencies, universities, and other research institutions. The unit will sub-contract surveys, as required, to national and international organizations with expertise in these areas, and build in the contracts the need for capacity building. At the provincial level, the CPLS will be responsible for supervising and monitoring activities funded at this level as well as consolidating information from their respective communities. Stakehold'rs will be encouraged to carry out periodic self assessments. Communities will be expected to focus mainly on monitoring simple process indicators and will be encouraged to carry out participatory assessments to measure the impact on beneficiaries and the involvement of PLWHA. How would the information be used to improve program performance? The Monitoring and Evaluation Unit of the CNLS in collaboration with TRAC will be responsible for disseminating information to relevant stakeholders. They will deterrnine how best to disseminate and subsequently operationalize the results of surveys and studies to meet the needs of different audiences (e.g. policy makers, implementing agencies, civil society). Information would need to be packaged differently depending on the goals to be attained (e.g. advocacy, behavior modification, program performance). What would be the key elements of the knowledge management strategy? Given the experimental and innovative aspects of the proposed project, as well as the post-conflict environment of Rwanda, knowledge management will be critical to the learning process. Establishing strong learning and feedback mechanisms will be essential to enhancing the possibility of adaptation and improvement of the project along the way. Knowledge management activities will have three key dimensions. First, within Rwanda, the emphasis would be on establishing and promoting a learning environment among all stakeholders. The CNLS will organize annual reviews to analyze technical and operational issues that emerge during previous year, in order to incorporate lessons learned into the planning process for the subsequent year. Workshops will be organized on a periodic basis, inviting those involved in carrying out HIV/AIDS plans to share their achievements, problems and solutions. It is anticipated that journalists would also participate in these workshops, in order to facilitate dissemination of lessons learned and to continue the process of sensitizing political and religious leaders. Finally, the project would provide funds to develop and publish a Best Practices Book, documenting these experiences. Second, Rwanda's participation in the MAP would facilitate South-South collaboration, enabling exchange of experiences and knowledge with other developing countries in the region facing similar challenges. Third, the establishment of a website for the national program, which is funded under the PHRD grant accompanying the Rwanda MAP, would be helpful in broadening access to information about HIV/AIDS and making available information from studies and surveys. This website would be gradually made available to other stakeholders in Rwanda as access to information technology improves at the provincial level. What would the 18-month evaluation focus on? As agreed upon during negotiations an evaluation would take place 18 months after grant effectiveness to assess overall implementation - 91 - performance. The main goal would be to review performance in order to take corrective actions to improve implementation. The evaluation would be done by an independent group and would serve as the basis for the the 18-month review between the Bank and the government. The evaluation would include the type of process indicators described below: Project Management The review of the Project Management Unit (PMtL) would take into account its strengths and weaknesses as well as those of other key entities, affecting its performance. The PMU will be assessed against its main functions, namely: a) facilitating the preparation, screening and approval of action plans, b) carrying out procurement and financial management functions, c) monitoring and reporting on project activities. Quantified measurement will include: * Percent of proposals receiving PMU response within timeframe established in approved Operations Manual; * Percent of action plans and civil society activities receiving funds, and taking procurement actions in accordance with time schedule and methodology established in the Operations Manual; * Number and quality of reports submitted and agreed to by CNLS. Action Plans The process of reviewing, screenng, approving and monitoring Action Plans would be measured by: * Levels of disbursement as compared to agreed upon disbursement plans; * Number of people sensitized and/or trained in safe sex behavior, as well as condom promotion, as compared to approved levels; * Number and quality of reports submitted by line ministry, CPLS and civil society organizations to the PMU. Civil Society Activities Civil society activities will be assessed, inter alia, in terms of whether civil society organizations are familiar with MAP requirements and procedures, whether the on granting mechanism is an effective tool in reaching civil society organizations, and the organizations are accessing the funds in a timely manner. This will be measured by: * Percent of funds going to civil society compared to agreed levels; * Percent of civil society proposals receiving a PMU substantive response within the timeframe set forth in the Operations Manual; * Overall geographic distribution of civil society activities.; * Regular civil society progress reporting to PMU. -92 - Additional Annex 12: Epidemiological Situation REPUBLIC OF RWANDA: Multi-Sectoral HIV/AIDS Project Background Infectious diseases - malaria, HIV/AIDS, STIs, and diarrhea - are the predominant cause of morbidity and mortality in Rwanda. According to the Ministry of Health, the major causes of the HIV/AIDS epidemic in Rwanda are the economic crisis, high rates of multiple sex partners, the early onset of sexual activity among young people, the widespread availability of commercial sex, in addition to cultural resistance to discussing sexually-related issues and condom use. The social structure of Rwanda has also changed significantly in recent years. More immediate threats to health, including violence and food insecurity, may cause people to be both more vulnerable to HIV infection and more fatalistic regarding their risk of contracting a disease that takes years to develop. The adult IV/AIDS prevalence in Rwanda is currently estimated to be between 11-13 percent. It is thought that at least half of adults living with HIV/AIDS are women. UNAIDS estimates that the epidemnic resulted in 49,000 deaths during 2001 alone. HIV seroprevalence among pregnant women ranges between 25-30 percent in Kigali, 10-20 percent in most other urban or semi-urban environments, and 3-15 percent in rural areas. Given the high levels of HIV prevalence and fertility rates, it is estimated that between 5,500-7,000 infants are born to HIV seropositive women annually. In the absence of intervention, an estimated 30-35 percent of these infants will become seropositive as a result of mother-to-child transmission. As elsewhere in much of Sub-Saharan Africa, HIV/AIDS has been found to exert a disproportionate impact on Rwandan women. This is especially true for adolescent women between the ages of 15-19 years, who are more likely to be infected than men in the same age group. Urban women have been found to be at greater risk of I-UV infection than rural women. Gender-based social vulnerability to HIV/AI1DS and poverty remains high, as women head 34 percent of households in Rwanda. Children (mostly girls) are currently reported to be heading 60,000 households and there are thought to be more than 3,000 street children in Kigali alone. Young people are also highly vulnerable to HIV infection. The WHV/AIDS prevalence rate among young people under twenty years of age, who comprise sixty percent of the total Rwandan population, was almost 10 percent in 1997. High levels of mortality among adults have contributed to the growing population of children who have lost one or both parents to AIDS. There are an estimated one million orphans (under 15 years) currently living in Rwanda (Rwanda: Epidemiologic Fact Sheet Update, UNAIDS/UNICEF/WHO, 2002). Although the initial major cause of orphanhood was the 1994 genocide, AIDS has made a substantial impact in more recent years. By 2000, it was estimated that 60 percent of Rwandan orphans lost their parent(s) to AIDS. This figure is expected to increase to over 80 percent by 2010, as indicated in the figure below (Rwanda and HIV/AIDS Country Profile, FMI, 1999). - 93 - Percentage of All Orphans Who Have Lost Parents to AIDS 90% 80% 70% 60% 30% 40% 0% 1 897 2000 Sourco: UNAIDS, 1998 HIV/AIDS has resulted in a major reduction in life expectancy at birth from about 50 years in 1985-90 to 42 years in 1995-2000. By 2005, it is estimated that the crude death rate in Rwanda will be 40 percent higher due to AIDS than it was in 1990. By 2015, AIDS is expected in increase Rwanda's already high infant mortality rate by 10 percent (Rwanda and IIIV/AIDS Country Profile, FHI, 1999). Infant Mortality Rate With and Without AIDS 300 250 200 10D 100 1X1so O0 ---Without AIDS -a--With AIDS 0 1985-1990 1990-1995 1995-2000 2000-2005 2005-201D 2010-2015 Snurco: UNAIDS. 1999 Health Sector Impact Rwanda's health sector currently possesses limited capacity to respond to the growing needs and impacts of HiIV/AIDS. The epidemic has worsened an already weak health system, as evidenced by declines in the number of medical consultations per capita witnessed over recent years. The number of hospital beds occupied by PLWHA rose from 9,000 in 1993 to 35,600 in 1997 - resulting in an estimated 50 percent of hospital capacity being occupied by AIDS-related cases. -94 - Box 1: Health Systems in Rwanda The Rwandan health system is a three-tiered structures, adninistered by the central MOH with four directorates (Planning, Finance, Pharmacy, and Health Services). The Treatment and Research AIDS Center (TRAC) is the branch of the MOH responsible for biomnedical aspects of HIV/AlDS prevention and care. The country includes 11 health regions and 39 health districts. Health centers serve an average population of 23,030, while district hospitals cater to about 217,500 Rwandans on average. The major challenges facing the health sector include: (i) linited human resources; (ii) lack of quality of health services; (iii) resource imbalances between tertiary and preventive and primary health services; (iv) accessibility, especially among the poorest strata of society. The HIV/AIDS epidemic continues to worsen an already serious situation. (Source: FHIIIMPACr, 2001). As in other African countries possessing a similar HIV/AIDS epidemic pattern, the incidence of tuberculosis (TB) is also rapidly increasing. More than half of all Rwandan adults have latent TB infection. Data correlating ILV infection and active TB in Rwanda are somewhat dated, but indicate that a range of 40-95 percent of TB patients in different locales were co-infected with HIV. On average, more than half of notified cases of TB also are found to be I3V sero-positive. The current trends in terms of increasing rural spread of HIV infection threatens to vastly increase the risk of TB for the entire population. Information on IHIV prevalence among male STI clinic attendees is available from Kigali since 1986. EHV prevalence was found to have reached 55 percent among men tested in 1988-90 and has remained relatively stable since then. In 1996, 55 percent of STI clinic patients in Biryogo (urban) tested positive and in the rural areas of Ruli and Kabgayi 13 to 42 percent of STI clients were found to be positive. More recent epidemiologic data on STI prevalence and incidence among men and women is limited. A baseline study on STIs with a particular focus on resistance and treatment success has not been conducted in Rwanda. The sections below provide more detailed information on levels and patterns of infection and behavioral change. Sero- and Behavioral Surveillance Data Prior to 1994, it is important to note that more seroprevalence studies had been conducted to understand the dynamics of the epidemic in Rwanda than in many other developing countries. These analyses revealed that the BIV/AIDS epidemnic had already reached high levels by the mid- to late-1980's. Studies conducted during this period demonstrate seroprevalence rates exceeding 80 percent among commercial sex workers in certain sites, above 50 percent among urban STI patients, and greater than 25 percent among pregnant women in Kigali. A national serosurvey conducted in 1986 estimated a prevalence rate of 16 percent among adults in urban areas and 1.3 percent among adults in rural areas, where 90 percent of the population lives. The political and social turmoil in the mid-1990's altered and exacerbated the course of the epidemic. The Rwandan conflict and its aftermath led to massive population movements, the rape of thousands of women (an estimated 40 percent of whom were below 20 years of age), and the extended residency of many thousands more in refugee camps. Newly established communal housing schemes ( imidugudu), involving the establishment of about 600 re-settled refugee households in a designated area, have created semi-urbanized conditions in many formerly "rural" areas, which, in the absence of - 95 - intervention, may further increase the risk of HIV transmission (Rwanda Country Program Plan, CDC, 2000, draft document). The Rwandan approach to HIV surveillance has been based on 10 major sentinel sites since 1997, most of which focus on antenatal clinic attendees. Surveillance data from antenatal clinics is available from Rwanda from the late-1980s. As previously referred to, in Kigali, IilV seropositivity among pregnant women was measured to be 32 percent in 1988, and was subsequently found to range between 25-33 percent between 1989 and 1995. However, the substantial fluctuations in the number of functional ANC sentinel sites between 1988-2000, has made it difficult to clearly identify and interpret trend data within this population (see figure below). Number of ANC Sentinel Sites (By Year) 12 10 8 -Otside mr*ar urban aias 8 6 s9 s9 St s-YearS9 9 ° Results of the 1997 Serosurvey The most significant surveillance effort to date was the 1997 population based serosurvey. This survey involved a total of 4,750 participants, of whom 63 percent were women, and was conducted in the catchment areas of five sentinel surveillance sites (Republic of Rwanda, Ministry of Health, Programme National de Lutte contre le SIDA, 1998, Population Based Serosurvey). The study estimated an adult prevalence rate of 11.1 percent, with nearly equal national rates among men (10.8 percent) and women (11.3 percent). However, among 20-34 year olds, women were 1.5 to 2 times more likely to be infected than men in the same age group. High prevalence rates were found in all prefectures involved in the survey: 13.1 percent in Kigali-urban, 13.9 percent in Kigali-rural, 11.6 percent in Butare, 11.0 percent in Umutara, and 5.8 percent in Kibungo. With the exception of Kibungo, the differences in rates between the prefectures did not achieve statistical significance. This survey significantly indicated that the gap between rural and urban HIV prevalence had narrowed in the recent years. Comparison with the 1986 survey indicated that rural rates had rapidly increased from 1.3 percent in 1986 to 11.6 percent in 1997. - 96 - Rural Rates of HIV Prevalence ID 4 2 0 Source: UNAIDS, 1998 Urban prevalence was estimated to be 10.8 percent. While urban-rural infection rates were close among the youngest age group (12-14 years), differences were most pronounced in the age group of 15-19 years with a rural rate of 8.5 percent and an urban rate of 3.4 percent. This rural-urban disparity was found to reverse in the age group 20-44 years, as prevalence in urban sites ranged between 16-24 percent, whereas rates were between 9-15 percent in rural areas. Significantly, the youngest age group (12-14 years) in the survey was found to have a prevalence rate of 4.1 percent, indicating a high proportion of new infections. Education status and likelihood of infection also revealed significant differences when disaggregated by age and gender, especially for adolescent girls. Girls (12-14 years) with no education had a prevalence rate of 9.4 percent in contrast to 5.0 percent among those who attended school. This education-attributable differential was less pronounced among boys in the same age group. In adults of age 20-29, a different pattern was found, as more educated women were slightly more likely to be seropositive than those with lesser levels of education. Conversely, more highly educated men were less likely to be infected. These patterns underscore the complexity of the epidemic patterns and the required responses. The study also found a strong association between HIV seropositivity and a history of reported STIs. Men with a history of urethral discharge in the 12 months prior to the survey were at least two times more likely to be HIV infected than men not reporting discharge. Women indicating genital sores in the last 12 months were 3 times more likely to be seropositive. It should be noted that although the study was conducted in diverse social and economic conditions, rural populations were underrepresented in the sample. This study was also unable to collect data on displaced persons due to transient living conditions. Although the survey provided critical information about the status of the epidemic, a more detailed epidemiologic profile is greatly needed. Major Behavioral Surveillance Studies In an effort to better understand the knowledge and behavior of certain population subgroups at increased risk of HIV infection, the Ministry of Health coordinated a series of comprehensive behavioral surveillance surveys (BSS) among commercial sex workers, transport sector workers, the military, and young people during 2000 in collaboration with technical partners. A number of other quantitative and qualitative studies have been conducted in recent years among various vulnerable populations. - 97 - The commercial sex workers BSS was conducted among 699 women in Kigali and Butare. The survey respondents ranged in age from 13 to 52 years, with a median age of 25 years in Butare and 22 years in Kigali. Nearly 70 percent of these women had attended (although not necessarily completed) primary school and 9 percent had also attended secondary school. Most women reported having had 2 to 5 sexual partners in the week preceding the survey. Ninety-one percent of women were familiar with male condoms and where they could be obtained. In the month preceding the survey, 58 percent of women reported using a condom with one or more clients. Only 17 percent of women reported using condoms with all clients. Over 70 percent of women did not use condoms with their personal (non-paying) partners. In the 12 months preceding the survey, 25 percent of women reported experiencing symptoms of an STI. Nearly 80 percent of women were able to correctly identify two means of preventing HIV transmission, indicating a high level of HIV/AIDS awareness. Thirty-six percent of women had been tested for HIV infection and had returned to collect their results Republic of Rwanda (Ministry of Health, Programme National de Lutte contre le SIDA, Enquete de surveillance des comportements (BSS) aupres des prostitutees, 2000). The transport sector survey was conducted among 481 men ranging in age from 15 to 64 years. Sixty-four percent had attended primary school and 31 percent had attended secondary school. In the 12 months preceding the survey, 40 percent of men reported having at least one occasional sex partner. Thirty-five percent of men reported having a sexual relationship with between 1-3 commercial sex workers during this same period. Six percent of men reported STI symptoms in the past 12 months. Among men reporting regular condom use, 47 percent of men used condoms with commercial sex workers and 31 percent with other occasional sex partners. HIV/AIDS knowledge levels were high among this group as 92 percent of men were able to correctly identify at least two means of HIV transmission. Of the 29 percent of respondents who had received HIV testing, 99 percent returned to the VCT site to obtain their result (Republic of Rwanda, Ministry of Health, Programme National de Lutte contre le SIDA, Enquete de surveillance des comportements aupres des routiers, 2000). The BSS conducted among young people (15-19 years) was the largest and involved 8,330 respondents, of whom about 60 percent were female. About 30 percent of boys and 12 percent of girls indicated that they were sexually active at the time of the survey. The mean age of first sexual encounter was 13 years for boys and 14 years among girls surveyed. Over half of sexually active girls reported having a current or former older partner, indicating a high level of age discordance among sexual partners. In the 12 months preceding the survey, 4 percent of boys and 5 percent of girls reported having symptoms of an STI. Condom use was very low among young people, as only 10 percent of young people reported ever using a condom. Girls' likelihood of condom use was about half that of boys of the same age in most study sites. Accurate knowledge regarding HIV transmission was found to increase with age and education level. Only 20 percent of young people were aware of the availability of VCT services and sites and only one percent of the study population has ever been tested. Of those tested, 71 percent of boys and 74 percent of girls obtained their test results (Republic of Rwanda, Ministry of Health, Programme National de Lutte contre le SIDA, Enquete de surveillance des comportements aupres des jeunes de 15-19 ans, 2000). The results of a more recent study served to validate the above findings (Republic of Rwanda, Kigali Health Institute, Analyse de la comprehension de la sexualite et du SIDA par la jeunesse Rwandaise). The survey of military personnel involved 664 respondents and revealed that although the men understood the basic facts about HV/AIDS, there was confusion regarding modes of HLV transmission. The most common source of HIV/AIDS information involved military health information sources followed by the radio. Among unmarried recruits, 40 percent reported having a casual sexual relationship that did not involve condom use, despite their widespread availability in the military. -98 - The above BSS surveys share a comm6n theme in that knowledge of the protective effects of condom use by far outweighed actual utilization with non-regular sexual partners. Such results add greater emphasis to the need for HIV/AIDS-related communication to shift from "general" IEC messages to more targeted approaches that address the behavior change among specific populations at increased risk of infection. With respect to perceptions regarding condom use, a survey conducted by PSI found that the majority of adults believe that it is acceptable for women to initiate condom use, and that only 46 percent of men and 36 percent of women think that the decision to use condoms should solely be made by men. However, despite these relatively positive attitudes, the study also indicated the continued presence of stigma surrounding condom use, especially by women. About half of all men and women surveyed stated their belief that women who purchase condoms are sex workers PSI/Rwanda (Rwanda sexual behavior and condom use survey, 1998). Conclusion As was previously stated, there remain substantial gaps regarding a detailed understanding of the magnitude and dynamics of the Rwandan epidemic. Data on HIV/AIDS prevalence in rural Rwanda, in particular remains very limited. The Ministry of Health appropriately emphasizes both the need for an significant improvement in both the generalizability and quality of surveillance data and an increased national capacity to achieve these goals. The conduct of a large-scale population-based serosurvey is under discussion and would be critical to a better understanding of the Rwandan epidemic, means of prioritizing resources, in addition to the development, monitoring, and evaluation of effective HIV/AIDS programs. Timely reporting of critical data and rapid data analysis is also seen as critical, as human resource lirnitations have resulted in lack of availability of the 1998-99 surveillance data. A thorough evaluation of the current surveillance system is under discussion to enable the development of a strengthened and expanded program. There is also a need to better integrate HIV, STI, and TB surveillance in order to develop a comprehensive and complementary epidemic profile. A move toward second generation HfIV surveillance would also appear key to improving the collection, analysis, and use of epidemiological data in Rwanda. Second generation HIV surveillance, as defined by UNAIDS and WHO, would assist national authorities both better monitor the epidemic and guide their responses to it. By relying on data collected from biological surveillance (serosurveillance), behavioral surveillance, and other relevant sources (e.g., HIV/AIDS case surveillance, death registration, sexually transmitted infection surveillance, tuberculosis surveillance), second generation data would support on-going research into new epidemiologic tools, improved methods for building estimates and epidemic modeling (including the identification of vulnerable subpopulations), and better means of using data for advocacy, planning, monitoring, and evaluation UNAIDS (Guidelines for using HIV testing technology in surveillance, 2001). A more comprehensive and flexible epidemiology program in Rwanda would be invaluable in assisting efforts to establish HIV work plans and priorities, monitor and evaluate programs, and evaluate the overall effectiveness of the national response to the epidemic. - 99 - Additional Annex 13: Project Supervision REPUBLIC OF RWANDA: Multi-Sectoral HIV/AIDS Project The project will need intensive supervision, given its multi-sectoral and multi agency nature and large span of activities. Moreover, the CNLS/PMU is a relatively young institution and many of the actors to be involved have relatively limited experience with Bank operations. Thus, this operation will require a much heavier than normal supervision effort. Some of the skills required for supervision will be needed on a regular basis while others will be required on an ad-hoc basis. It is therefore proposed to establish a core supervision team, which would be complemented by other technical specialists, as agreed upon with the govemment team. The core team would carry out, on average, 3 two-week supervision/technical support missions annually comprising of up to 6 staff, depending on the issues to be tackled during a specific mission. Other technical experts would provide support periodically, as required. During the first year of the project, the Bank would explore the possibilities of recruiting a consultant(s) to provide technical backstopping, possibly financed from a trust fund. This person(s) would be well placed to provide regular inputs to Bank supervision missions and to troubleshoot at an early stage. The core team would be comprised of the following experts from headquarters and from country offices in Rwanda and in neighboring countries who have played a pivotal role in the preparation phase: (i) task team leader with experience in health projects, with particular focus on HIV/AIDS operations; (ii) deputy task team leader, who would provide intensive follow up in between missions; (iii) operational specialist who would oversee day to day implementation of project in country; (iv) social protection specialist who would assist with design and monitoring of interventions aimed at mitigating the socio-economic impact of the epidemic, including experience working in post-conflict settings working with orphans and vulnerable children; (v) financial management specialist who would review adherence to Bank procedures with regard to fiduciary responsibilities; and (vi) procurement/implementation specialist who would be responsible for the procurement, implementation and institutional issues. The core team would also comprise of representatives of Rwanda's development partners active in the fight against HIV/AIDS. As during the preparation process, partners would be invited to participate on supervision missions to ensure complementarity of interventions, build strong partnerships and facilitate a cross fertilization of experiences. The core team would visit each participating province at least once a year, either by themselves or accompanied by other specialists. For the first year, a total of 39 staff weeks are planned, of which 22 headquarter staff weeks and 17 country office staff weeks; these amounts would be reduced to 19 and 16 for the second year, and 15 and 16, respectively for the third year as the country office assumes greater responsibility for the supervision of the project: The core team would be complemented with other technical experts in the following areas: (a) sector specialists (e.g. rural development, education, transport, mining, energy, private sector) to review progress in respective sector; (b) monitoring and evaluation; (c) public health, with focus on communicable disease control; (d) communications specialist to review ]IEC/BCC interventions; (e) economists to assist in priority setting and in monitoring the impact of the epidemic on households, (f) anthropologists/social scientists to explore the social and psychological aspects of the disease; and/or (g) post-conflict specialists. The Bank budget covers roughly 11 staff weeks of headquarters/country office staff for (a) and - 100 - (b) above. The remaining specialists would need to be recruited on trust fund resources, as deemed necessary. A minimum budgetary allocation of US$150,000 would be needed each fiscal year and would be allocated as described below. Furthermore, an additional $50,000 would be needed during the first two years of learning to jump-start the orphans and vulnerable children activities under the MAP, working in close collaboration with other development partners. Core Team 39 78% Health/Social Protection 29 Inst./Finan./Procurement 10 Sector and Technical Specialists 11 22% Rural Development 5 Transport/Mining/Energy/Private 3 Education 1 Monitoring & Evaluation 2 TOTAL 50 - 101 - Additional Annex 14 Orphans and Vulnerable Children REPUBLIC OF RWANDA: Multi-Sectoral HIVWAIDS Project Situation Analysis, Programmatic Approaches & Scaling Up Overview of the Rwandan Situation Rwanda is faced with a number of circumstances that have and will threaten the well-being of its citizens, particularly children. The 1994 genocide has had and will continue to have far-reaching effects. HIV/AIDS is rampant among the adult population, causing early death of many of the remaining adults, leaving few to care for the growing population of children. Other adults are in exile or imprisoned. Political unrest in surrounding countries continues to pose a threat. Almost half of Rwanda's population is under age 15 years, and more than a third of all households are headed by women. Only around 10% of the adult population has completed primary school. Fewer than 10% of houses have electricity and only 4% have water piped into their yard. Most women (79%) work; however, most of those are self employed and do not earn cash. Child mortality is high: 20% dying before their fifth birthday. HIV infects from I 1%-13% of the adult population; treatment and care programs are very limited; and prevention efforts have resulted in a high level of knowledge about AIDS, but little in the way of prevention of infection. Many children are orphaned. An estimated 187,000 have lost their mother 293,000 their father, and 66,000 both parents. The population of Rwanda is largely rural and tends to be dispersed throughout the country. The lack of any real village structure, unique in Africa, has necessitated the creation of population and geographic divisions for administrative purposes. The country is divided into 12 provinces, 92 districts, 1545 sectors, and 9,185 cellules. Finally, one person is responsible for every ten families, a group referred to as Nyumbakumi. The commune is the smallest administrative unit; sectors and cells are not political entities with a legal status. This hierarchical system works well for disseminating information from the top down, but not necessarily from the bottom up. However, there is a movement to decentralize, giving major decision-making autonomy to the communes. The social framework for caring for widows, orphans, and vulnerable families and children has long been the extended family. However, with so many adults killed, dying, imprisoned, or exiled, this system that has been used for generations is heavily stressed, and the needs of many young children and their families are not being met. Young children, especially those under 5 years of age, are particularly vulnerable to the effects of inadequate care during these early years. Poor health, malnutrition, little stimulation resulting from inadequate care can all effect the child's ability to think, learn, and function effectively. These effects are likely to have long-term consequences that are irreversible, both for the individual child and collectively, for society. International Experience Throughout Africa, national governments have begun to develop policies and programs to support OVC, and many local grass roots efforts have been established to help provide a safety net for jeopardized families and children. Many of these programs are run by local groups, charities, and religious organizations, often with few resources, and with assistance of volunteers. A few large programs have been implemented and evaluated. - 102 - UNICEF has published a document, Children Orphaned by AIDS: Front-line responses from eastern and southern Africa (December 1999), that outlines programs in 4 countries: Botswana, Malawi, Zambia, and Zimbabwe. Common themes include: * The need for political will, policy guidelines, and support at the national level. * Registration of OVC and tracking through formation of a database. * Community-based provision of care for OVC, with institutionalization as a very last resort. * Engagement of NGOs, religious-based organizations, and Community Based Organizations (CBOs) at the local level * Coordination between the NGOs, CBOs, and government. The Abbott Laboratories Fund supports the Step Forward for the World's Children program in Tanzania and Burkina Faso, focusing on 4 areas of support: health care, education, voluntary counseling and testing for H[V, and basic community needs. The Fund has provided support for existing orphanages to cover material items (food, medicines), repair of buildings, and improvement in sewage and water systems. In communities, schools have been repaired, hospitals have been supplied with needed medical supplies, and IJV counseling and testing has been expanded. Training for income generating activities has also been conducted. Community based organizations have been reinforced and mobilized. In Zimbabwe, a religious-based organization has established a program that extends to 9 project areas in Manicaland Province; 180 community volunteers support about 3000 orphan households. The program is community-based and delivered by local CBOs, using the local volunteers to assist caregivers, assess material needs, and small-scale distribution of material assistance. The program also provides training and support, funding for school fees, and overall project management. The project costs about $20,000 US per year, and about $40 US per household per year. Families receive about 4 visits per month. The underlying long-range idea is for the project to concentrate on capacity building of CBOs and NGOs, rather than direct intervention. UNICEF has sponsored a cost-effectiveness analysis of 6 models of care for OVC in South Africa, representing models ranging from the informal to formal structures: (i) fostering/non statutory; (ii) community-based support; (iii) home-based care and support; (iv) unregistered residential care; (v) statutory adoption and foster care and (vi) statutory residential care. The study found that costs were high for formal models of care, but that informal models often suffered from lack of access to resources. The most cost-effective programs were those based in the. community; however, to be successful, these models need infrastructure building, training, and financial and resource support. Although the formal models were the most expensive, they provided two types of care that was otherwise very difficult to provide: emergency care and care for very ill children. - 103 - Rwandan Activities USAID has published a report, USAID Project Profiles: Children Affected by HIV/AIDS (October 2001), describing activities in 14 countries in Africa, 3 in Asia, 2 in eastern Europe, and 3 in Latin America/Caribbean. The report contains summaries of 53 country-specific projects and 9 global and regional initiatives that include activities to benefit children affected by HIV/AIDS. The Rwandan project described is the Safety Net and Leadership Initiative for Fighting Epidemics (LIFE) Food Programs. The LIFE component aims to provide food to 22,000 AIDS-affected children (4,400 households) per month to supplement their nutritional requirements. Beneficiaries include child-headed households, children orphaned by AIDS, families with HIV-positive parents, families with I{V-positive children, and families with foster children who are AIDS orphans. Food assistance will be linked with HIV/AIDS education, home-based care, counseling, occasional assistance with school and health fees, vocational training, and income-generation activities provided by sub-grantee agencies. This program is currently in the early stages. Best Practice Most of the successful programs involve establishment of local community committees to detect, monitor, and assist vulnerable families and children. Typical projects include establishing local community gardens, childcare centers, income generating projects, micro credit, expanding the educational system and assistance with school fees, and expansion of health services. Assistance in organizing local communities, training, resource management and provision, and infrastructure building are critically important. Community volunteers serve as a critical means of providing services to families. Community mobilization to ensure commitment and strong leadership is also necessary. Scalng up The MAP aims to channel funds to support the work of NGOs, community groups, religious groups, women's groups, youth groups, labor unions, private enterprises, and associations of People Living with AIDS through the civil society component. Activities targeted to orphans and vulnerable children are expected to figure prominently under this component. The govemment is currently in the preparatory phase of this initiative. Four NGOs are conducting surveys in 4 districts in Rwanda to assess the needs of young children. The next phase will involve using the data collected from the surveys to design and implement programs to meet the identified needs. These pilot programs will serve as the basis for scaling up these activities. The survey covers a number of potential basic needs of the family and the OVC, including housing, material needs, health, food security, education, legal needs, and emotional development. From the survey, estimates of the number of children per household and the percentage of orphans and other vulnerable children can be determined. Survey data will be available in late November 2002, and a workshop to discuss the data and next steps for the project will be held in early December. The goal of this sub-component is to assure that all children have their basic needs met (as defined in Figure 1) through: (a) building a community-based, sustainable program for OVC case management and (b) providing services through increased support for government and non-government community institutions and services. The specific objectives and strategies would include: - 104- Objectives Strategies Lead Organization Identification of existing * Conduct situation * Provincial-level NGOs resources within the analysis in target community, such as other community programs (micro credit, Ref:i J Williamson, agriculture, income UNICEF document, generating, health education, Attachment H mental health), government services (healthcare, education, social welfare), com.munity groups/NGOs, churches, legal services Determine gaps in existing * Engage key Provincial-level NGOs' resources stakeholders and key agencies identified in Establish or enhance the situation analysis to comrnmunity plan for review overall findings, addressing these gaps to meet agree on what's needed the needs of OVCs and their in the community, and farnilies how the community can develop their own strategies for Provincial-level NGOs prioritizing and meeting forn Community these needs Planning group * Develop process for continued collaboration and coordination among * Community Planning the key stakeholders group with provincial- and service providers level NGOs as * Develop process for Secretariate assuring the authority of the OVC program to obtain services for OVCs and their families Establish system for * Analysis of data from * Provincial-Level identification and enrollment survey to determine NGOS in collaboration of families with orphaned program eligibility with Task Force and vulnerable children * Determine ways to consultant identify eligible * Task Force consultant families: mapping exercise, ongoing referral (Ref: AXIOS) * Develop marketing plan * Provincial-level NGOs to encourage with Task Force participation consultant - 105- For each province or other designated geographic area, an NGO with the following characteristics will be designated as the leading organization for that geographic area: e Substantial capacity and experience, including "track record" of accomplishments. o Financial capacity to manage smaller sub-grants to other organizations. o Managerial and organizational skills and reputation to organize and oversee activities of smaller organizations. o Sufficient technical ability and expertise to provide assistance to smaller organizations. o Sophistication in working with large donor organizations and governments to carry out the requirements, both technical and financial. These NGOs will be responsible for implementing community-based programs in their province. They will be responsible for establishing 2 mechanisms for meeting the needs of OVC: o Organizing and managing a case management system for identifying the most vulnerable families, assessing their needs, linking them to services, providing them with emotional support, and advocating for these families. The large NGOs will provide oversight for the case management system; the local NGOs and other CBOs in the province will run the daily operations of the case management system. Resources for these smaller organizations will be allocated through sub-grants from the larger NGOs. In addition to oversight and management, the larger NGOs will also provide training and technical assistance. Individuals from the community will be trained as case managers. Each case manager will have a caseload of about 10-30 families. Once or twice each month, case managers will conduct structured assessments and home visits to determine the needs and progress in meeting needs of each of their assigned families. The case managers will report to local NGOs/CBOs, who will oversee the day-to-day activities of the case managers. The larger/district-level NGOs will provide oversight of the entire project, training of smaller NGO staff, case managers, other technical assistance, and assure that the needs expressed by the farnilies are communicated to the Community Planning group. The larger NGOs will also be responsible for evaluation of the project. The generally accepted principles of case management will be used to design an effective and responsive case management system for meeting the needs of vulnerable families and children. O Serving as the Secretariat for Community Planning groups These groups would be responsible for identification of community resources, determination of gaps in resources, prioritization of community needs with respect to OVC, and advocacy for resource generation. While the case management system serves the needy population, the Community Planning group assures that the community services are available to the case managers for referral of children and families. -106- Figure l: Basic Needs of Children, Components of Programs Component Type of Program Health * Expansion of clinics and o Health status of children services and caregivers * Fee subsidies o Access to health care * Transportation programs (e.g., travel, wait time, Mobile clinics payment) * Health education of o Caregiver's knowledge of family/community and ability to care for * HIV/AIDS prevention sick child o HIV/AIDS * Water and Sewage * Community improvements * Health education * Food security * Direct transfer of goods to o Nutrition family-Short term assistance o Family's ability to only provide food * Community feeding posts * Community garden * Health education * Education * Community day care centers o Preschool care and * Subsidies of school fees stimulation * Direct transfer of school o School attendance (fees, supplies to family uniforms, materials) o Barriers to school attendance * Material needs * Direct transfer of goods- o. Clothes, bedding Short term assistance only * Housing *. Repair by volunteers o Adequate structure * Relocation o Safety and security * Community advocacy * Legal needs * Provide legal assistance o Wills, adoption, fostering * Family income * Job training o Income generation * Micro credit program o Agriculture * Farm assistance o Need for children to work * Child rights protection to generate income -107- Additional Annex 15: HIVAMDS Donor Activities REPUBLIC OF RWANDA: Multi-Sectoral HEIWAIDDS Project A. Interventions basees sur la recherche bio-m6dicale (transfusion sanguine, surveillance 6pid mioIogigue,_laboratoire, VCT et MPMTCT) en milieuz hospitaliers N Project Area of Beneficiaries Amount Source of Coverage Organisation/ Contact Comments I /Programme Intervention invested and funds Institution person and on title period address implementati covered _ _ __ _ on 1 Programme de Securite Population 308.927$ US - Gvt Tout le pays MINISANTE Dr. Jean Moyens transfusion transfusion generale - OMS Nkurunziza logistiques et sanguine nelle - Commission Tel :570407 budgetaires Annee 2002 Europeenne insuffisants. 08562803 2 Laboratoire Recherche Population 2.900.000 Projet Tout le paysi TRAC / Dr John Moyens National de bio-medicale generale et Euros Lux-Dvipt MINISANTE Rusine stationnaires reference aux CD4 et PWIH Tel: mais demande ARV Charge virale 2001 - 2006 08410398 en augmentation 3 Programme de Prevention et Mbres 346.048 $ UNICEF, ONIS Tout le pays TRAC / Mme Solonge Reponse tres PMTCT prise en seropositives EG, PAF, 37 sites MINISANTE Shengero favorable de la charge et leurs Annee 2002 Primell, Impact PMTCT Tel: 578471 population nouveaux nes 4 Surveillance Surveillance Femmes 830.000 $ US Impact - Tout le pays TRAC / Dr 25 sites 6pidemiologique 6pidemiologi enceintes Rwanda 25 sites MINISANTE Kayirangwa opbrationnelle par sites que 2002-2003 CDC Atlanta 2 sites par Eugenie s sentinelles province Tel: depuis 2001 ( 1 urbain,1 08426470 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___ _ _ _ _ _ _ _ _ ___ rural) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ur l 5 Initiative Surveillance Population de 500.000 $ US Cooperation/ 2 districts TRAC I OMS Dr. Ntazinda Bonne OMSAtalie VCT / MTCT 2 districts Italie medicaux Gaspard adhesion de la IST 2001 - 2003 Tel :578471 population au Kigeme, projet Nyagatare - 108 - N Project Area of Beneficiaries Amount Sourno ot Coverage OFrg1rwisatIO "ontact 1oniwienlSon; l'. rip mme title tnterventlon . Invest!d and funds. r/ p.rsoeh and implementaAl; > ez. ;- I, , e cpfriod Inst4tillon add oss _________ ~~~covered- 6 Programme de epistage et Population 185.475 $ US USAID & CDC 18 Sites dans TRAC/ Dr. Joseph Collaboration unselling et ounselling g6n6rale ATLANTA Provinces Impact - Nibarere vec les esting volontaire Centres de VCT Rwanda Tel: 578471 tructures 28 centres sur mdicales out le pays) emande en _ ~ ~ ~ _ __ _ _ _ ______________ _____ ugmentation 7 PMTCT revention Pregnant women ee annexe SAID & CDC Sites in Impact - Deborah Partnership with 2 tlanla Provinces Rwanda Muray medical services Kabgayi, Tel.: 576193 Rwagana 570764 iryogo, ungwe Nombre inclus ans les 37 ites/ Cf r N°3 _ _ _ _ _ _ _ _ ___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ TR A C ) 8 CT - Kanombe revention el Milftaires , leurs 45.263 $ US Impact Camp mililaire MINADEF/ Charles Bonne urveillance de familles et la FH1/USAID e Kanombe et FDR Murego nt6gration du 'epid6mie population des es environs Tel: rojet dans les snvirons Ann6e 2002 08301049 ervicesdu ____________ _________ ___________ _________ _________ ____I___ M IN A DEF/FDR -109 - A. Interventions axies sur la pr6venton par l'IEC, la CCC (et le counselling) notammnt auprbs des leunes des femmes et autrees mem s db la communaute i'.v~irvn~*. Arof> -mSgwfolnkM ; etiri e,iff .tw7 Orgains ,V fvioni cOU 1 . ;r I $U,itwnftbnt f ft - an,4;dod \5* ' ,, InrJhjlo udaddtfffe bupern'1en 9 Preton program Preverton Youth 15-25 717.687 $ US USAID 4 Prcnces lIp- Deborah Muray Panershp Mith for youth (15-25) lKgali, uye , Rwanda Tel. 576193 church orgarssationrs Qsenyi, Byunrbfa 570764 10 Moboign for Ufe Strenghening Gerera popuialion 244.412 $ USAID Kiga dty& Word Relief Ngoga Enianuel Works through the church PLfWHA Kfiga lnrau Box6052 Td: 08454598 churd'eusingthir response 1999- 2002 Ruheneil Igifati capadty for reahring _f__ _ugu their wide winstituenr 11 Counsdlnrg and Prevention churcih leaders 129.310$ Norwegan Tout Il pays RCCTC Jaoqueline Meets commurtT y training progranne- Conm tifies daiurcdh Aid Muk ra needs in oounserlng orgainsations 2002- 2003 Tel: 571743 .____ ___ _______ ____ Moeb.: 08534692 tft . . . ninv~1pnf', O . . d4 - tu1 Ins ,titto l . . 11 irt andattdmss ntuadd tr' 12 Prqet \fVSlDA Prevention Bhvesde fin 6cole Fonds propres 2 provinces MSF-Betg,que Dr Georges Eidension Ac fautres Ecotes pnme,re, 5" et MSF Kigali aty et BUSSIOS provinoes erwvsag6e. 6b-annres Cyangugu Tf3 519024 13 Rentforoenrnt des Prevenftion A Femms at filles Conmruty 6 distridts daens 6 ACORD M. Frangc*s Contrarntes ai nettre droits soao- base diets d mennages 42.004$ US Fund UK provinces Kibungo, Munyentwari en suvre I'approche cmoniques des conmunautai (9000 mnnages) GitarUmutara, Tel :574619 de prverition feresf et filles crefs re FUrung et Kbuye communautaire de rr6fnag__s 2002-2004 14 KigaJi vocatonal Preventon et Jeunes nDn 248.966 $ US UNICEF & 1 dstrid AFRICARE M. Cary Alan Travail avec tes sdoo Integrated appui aux scolansds, leunes Donor urbain: Kanonrbe Johnson jeunes trbs Deopment PWH dans les icodes de Fondation 1 dstrct Tel: 577484 prometteur. Ackve mbters et Pv\IH 2002 - 2003 rural: Kabuga Difficuties atravabler avec ies PVVIH. 15 Condom Soaal Preventon Population 5 nillioris de DM KFW Tout le pays PSURWANDA Lisa SIMUTANI Strgnra non eicore Marketing sexuellemert acbve 2001- 2004 Tel: 585137 leve surtout en rnlieu rural 16 BCC using Prevention - Jeunes 900.000 pouds DFID Tout e pays, PSVRWANDA Lisa SIMUTANI Collaboration avec las interpersonal * Prostituees surtout le mnlieu Tel* 585137 volontaires de la sante comrunications Leaders politiques rural. pour r&ussir la et rerigeux 2001 - 2004 dstnbubon au niveau I___________ ________ ommunaut are 17 Prograne sectorel Prevention et Jeunes 68.965 $ US ONUSIDA Via Tout le pays Co1,sei1 John FRusbi Co programme a cree de lute cotre le pnse en UNCEF Ntional dela Tel: 08519430 le reseau des FOJAS SIDA chez les jeunes dcar,e Jeunesse du (Forum des leunes Rwanda anti-SIDA) dans tous (C_R_ _les cistncts du pays. 18 Prevenbon du VIH en Preventon Jeunesse 1000.000 $ US World barik Tout le pays MINEDUC Emmanuel Personnel insuffisant rnlieux scolaires scdarisee et leurs 2001 - 2005 Rusanganwa par rapport au nombre _ducateurs = == __ Tel- 585258 d6coles. - 110- A. Interventions axees sur la prevention par l'IEC, ia CCC (et l counselling) notamment aupres des leunes des femmes et autres membres de la cornmunaute N° Pro tpogame . .ne ales Anw nt Iit Soe of Covege Organ,atiooV Contact perso Commen1% on . -,j tite nlsieti& and q3d X dso bttuW n 1- andldss . impmentdtdn 9 Prevenbon program Prevention Youth 15-25 717.687 $ US USAID 4 Provinces Impact - Deborah Muray Partnership With 1or youth (15-25) Kgall, ldbuye, Rwanda Tel.: 576193 church organisations ________ Gisenyi, Byumba 570764 10 Mobilizing for fife Strengtening General populabon 244.412 $ USAID lKgali dty & Word Relief Ngoga Emmanuel Works through the church PLWHA Kigali rural Box 6052 Tel: 08454598 churches using their response 1999- 2002 Ruhengen Kigali capacity for reaching Cyanaugu their wide consttuency 11 Counselling and Prevention church leaders 129 310$ Norweglan Tout le pays RCCTC Jacqueline Meets community tramining programme - Commumbes church Aid Mukangira needs in counseling organisations 2002 - 2003 Tel: 571743 ________ Mob. : 08534692 N o Ptoet IProgameri fot w ciau1es A nio nvsted . Src of Coverage Organiisatlnoe Contact prson Cmnients an tIt , . le Iiq. . . . and od ; t. ms , InsfIutIon #i ,i d ss implebrrentation 12 Projet VIH/SIDA Preventon Eeves de tin ecole Fonds propres 2 provinces MSF-Belgique Dr Georpes Extension A d'autres Ecoles pnmaire, 5t at MSF Kigai cty et BUSSIOS provinces envisagee. "6 ann6es Cyangugu Tel: 519024 13 Rentorcement des Prevention b Femnies et files Community 6 distncts dans 6 ACORD M. Frangois Contraintes a mettre droits socio- base chefs de menages 42.004 $ US Fund UK provinces: Kibungo, Munyentwan en ceuvre I'approche 6conomrques des communautai (9000 menages) GitarlUnmutara, Tel :574619 de preventlon lemmes et filles chefs re Ruheng et Kibuye communaulaire de menages 2002-2004 _ 14 Kigali vocaional Prevenbon et Jeunes non 248.966 $ US UNICEF & I district AFRICARE M. Cary Alan Travail avec las schoolIntegrated appu aux scolanses, jeunes Donor urbain' Kanombe Johnson jeunes tres Devebpment PVVIH dans les ecoles de Fondabon 1 distridct Tel 577484 promenteur. Acfivtires metbers et PVVIH 2002 - 2003 rural Kabuga Difficult6s A travailler I.I avec les PVVIH. 15 Condom Socal Prevention Population 5 milbons de DM KFW Tout le pays PSVRWANDA Lisa SIMUTANI Stma non encore Marketng sexuellement active 2001 - 2004 Tel. 585137 levA surtout en milieu ________ n_______ __________ rural 16 BCC using Preventon - Jeunes 900.000 pouds DFID Tout le pays, PSVRWANDA Usa SIMUTANI Collaboraton avec les interpersonal * Prostituees surtout le milieu Tel: 585137 volontalres de la sante communicabons * Leaders polibques rural. pour reussir la at relgieux 2001 - 2004 dIstribut ion au niveau et__________2001_*_2004 communautaire 17 Programme sedoriel Prevention et Jeunes 68.966 $ US ONUSIDA Via Tout le pays Consel John Rusimbl Ce programme a cree de lute contre Is pnse en UNICEF National de la Tel: 08519430 le reseau des FOJAS SIDA chez les jeunes charge Jeunesse du (Forum des jeunes Rwanda anti-SIDA) dans tous (CNJR) les disricts du pays. 18 Prevenbion du VIH en Preventon Jeunesse 3.000.000 $ US World bank Tout le pays MINEDUC Emmanuel Personnel insuffisant milieux scolaires scolansee et leurs 2001 - 2005 Rusanganwa par rapport au nombre educateurs . Tel: 585256 d'coles. . =~~~~~-11 C Inteve ons axes la pdse en charge m dco-social et/ou par r apprdce comnunautaire Wsant,rdpondre aux besdns du PV/Het des failies affectes N Pr Pmo glie Ameso Sh fll n d Sou.o Cow" rpnil. Conts paison Conunton 'tWitl Iisienton ,tr~ . klf,llo a,w, . ....... t^ t" u;;+s drluu 1 36 Prowctu and dvocacy & Vulnerabbs gop 12284$ UNFPA Taut l pays Bureau de la Dr Ag- s Les fods mobils6es Carei d talfies Social Chldr & farrifas dmarra t Prenii3re Binagwaho vont drectement aux Against HIV/AIDS mobilizaon Youth Dame T6l: 583018 ionsaoccupant (PACFA) Care Wo\en 3.309 $ UNICEF 085053 des grupes plan strat ANSP+ vuinkbles. PACFA GIPAaoncept PVH assure le suM ae Ptmorbon 323275 $ Dimrs lutilsatfion des fonds AVEGA 37 Assistance aux - IEC - Eants non Vres en nature GAt et Tout le pays MINALOC M. Straton Parteniat avec des grupesvuinrables Counsellrg a donatsaurs N zabagam owures humenitaires - Si3c u nb3 - Farrl1es affeces Tl: 83595 (CRS, PAK..) alcTentaire par leVIH 3s Pritg ard - Pdsa en Femm s vGdmues t bs paures strenglhening dharge de violence et 3918.852 $ Donosm 4 Provinces: KigKli Rvwnda kAm Mary et traumratises strategies that rnfddo-sociale fermies infectees City, Kigali Rural, Woren's Balikrged - Infections enopwer Rwendan - Habtat et par le VIHVSI DA Ruhenged, Umruara Netork Tel- 83662 frequentes A cause de women adct6s la pauvret. gbneratries de revenus 12001 - 2005 39 T B. and cppcrtaust Medoa care PHIWHA USAID 2 Hospitals in Inpat - Deborah Muray Parinership with infections Gitar et Kbungo Rwanda Tel: 576193 medical services Kabgayi et 570764 40 Association Counseling et prostrtuees Butare Ville et ses Association Sr Genrvieve Approche intge de 'Arbre de vie' adt6tis erirons Arbre de vie Tet: counselling chretien et gAmnratices. soutien social de revenus 41 Homnebased care Care FUWIA 94.704 $ US USAJD Kigali City Inpact- Deborah MWray Partnership with the Rwarnda Tel.: 576193 National association d 570764 PLWHA ( ANSP+) 42 Support to Scahng up Carnes & 320.674 $ Posnansky Tout le pays AdorAl D/ Ndintat Claver PaFnrship with the counselling, prngramnmtc vutnerable groups UK 12 provnces Rwanda Tel: 587240 conrnurc6es Treatrment and interventions Research 2002 -204 43 Miro projects Support to PLMHA 150.864$ Normgian Kigali City RCCTC Jacqueline Context d poverty arm PLWvIA vulnerable dcurch Aid Mukangira traurrm RCCTC is groups 2002-2003 Tel: 571743 also involved in _ _ obb. . 08534892 hearing. 44 Ptoect dappui aux PNse en Fenimes et fi0es SURF 6 provinces Associaton Consolie Forte deande en personnes irrfectes charge victires de violence 164.192 $ US Survivors Furd Kig ville, Kig nural, desveuvesdu Mukanylliglra nsficamtents et en (PAPI) m6ldicale et U.K Kibungo, Butare, GAnocide Tel: 516125 counselling socwo- bbuyeet Gitarama AVEGA 08520122 _ _ _r__ _ qu_ Juin 2001 juin 2002 I I I I 45 Proqet FVISDA Vdet - Depistage Personnes 300.000 EUIOS Fords propres I gali City MSF-Belgique Dr GeoC es Dernandb de soins rndical PMTCT infectees MSF BUSSIOS- en augnentaton - 112 - NIGERIA L CHAD_/ S-< O29° 30° 31° t r/ /> i AFRICAN REPUBUC K 2 ',^^^ewOONz r. < - 9 <8\S r < / j ~~~U G A N D A ;IJ~L , f .' i ' ,_e KENYA ' U G A N DAwr7 'N ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~T. *,-..9 BEEs_ iRt ogomo <' L'kTi. 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